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Frontispiece. 


SURGICAL    ASEPSIS. 


/^C^Cii' 


I.  Ycast-gcrms  from  lager  beer.  2.  Zobgloia.  3.  Culture  of  staphylococcus  pyogenes  citreus 
on  potato.  4.  Staphylococcus  pyogenes  aureus,  from  an  agar  culture.  5.  Streptococcus  pyogenes, 
from  phlegmonous  pus. 


Saunters'  Nei»  ^iti  Series 


A    MANUAL   OF 


THE  MODERN  THEORY  AND  TECHNIQUE  OF 


SURGICAL  ASEPSIS 


BY 


CARL   BECK,  M.D., 

Visiting  Surgeon  to  St.  Mark's  Hospital  and  to  the  German 

POLIKLINIK    OF    NeW    YoRK    CiTY,    ETC. 


WITH  65  ILLUSTRATIONS  IN  THE  TEXT, 
AND  12  FULL-PAGE  PLATES 


PHILADELPHIA 

W.    B.    SAUNDERS 

925  Walnut  Street. 
1895. 


Copyright,  1895,  by 
W.     B.    SAUNDERS 


PRESS  OF 
ELECTROTVPED  BY  ^     ^     SAUNDERS,   PHILADA. 

WESTCOTT   &   THOMSON.    PHILADA. 


7^ 


TO    THE    MEMORY 


OF 


BERNHARD   von   LANGENBECK, 


THE  GREAT  SURGEON  AND   PHILANTHROPIST. 


PREFACE. 


This  Manual  of  Surgical  Asepsis,  which  is  based  upon 
the  method  employed  in  my  teaching  upon  the  treatment 
of  wounds  at  the  New  York  Post-Graduate  School  and 
at  St.  Mark's  Hospital,  was  written  in  compliance  with 
the  solicitations  of  those  practitioners  whom  it  has  been 
my  pleasure  to  instruct  at  these  institutions. 

As  it  is  only  within  a  comparatively  few  years  that 
bacteriology  has  revolutionized  the  practice  of  surger)^, 
it  is  natural  that  even  the  most  excellent  surgical  text- 
books lack  full  and  detailed  descriptions  of  the  theory 
and  technique  of  surgical  asepsis. 

While  the  leading  idea  has  been  to  write  a  practical 
book  that  would  in  a  measure  meet  the  deficiency  of 
the  larger  works  on  the  subject,  yet  tlicory  could  not 
entirely  be  omitted,  inasmuch  as  most  of  the  technique 
of  modern  wound-treatment  is  founded  upon  experi- 
ments conducted  in  the  laboratory.  But  only  those 
experiments  have  been  accentuated  whose  comprehen- 
sion is  indispensably  associated  with  that  of  technique, 
and  whose  results  can  be  corroborated  by  clinical  obser- 
vation.    Hence  in  this  treatise  there  has  been  followed  a 

5 


8    ^  PREFACE. 

gratitude  also  to  Drs.  Schlange,  Schimmelbusch,  Braatz, 
and  Schmidt,  who  so  materially  aided  further  investi- 
gations of  asepsis  at  the  University  clinics  of  Berlin  and 
Heidelberg. 

In  conclusion  I  desire  to  thank  Dr.  F.  C.  Valentine  for 
his  most  efficient  assistance  in  revising  the  proofs,  and 
Mr.  John  Vansant  for  the  valuable  labor  he  so  cheerfully 
performed.  My  thanks  are  likewise  due  to  Mr.  W.  B, 
Saunders  for  the  typographical  and  pictorial  excellence 

of  the  work. 

CARL  BECK. 
37  E.  3 1  ST  St.,  New  York, 
March,  1895. 


CONTENTS. 


PAGE 

Introduction 13 

I. — Influence  of  Microbes 17 

Sepsis,  17  ;  Asepsis,  17  ;  Micro-organisms,  17  ; 
Pathogenous  Microbes,  21  ;  Xon-pathogenous 
Microbes,  22  ;  Cocci,  22,  ;  Bacilli,  24  ;  Aerobic 
Microbes,  2"]  ;  Anaerobic  Microbes,  27  ;  Isolating 
and  Cultivating  Microbes,  29 ;  Toxines,  35  ; 
Chemotaxis,  35  ;  P3-ogenic  Cocci,  36  ;  Staph3'lo- 
coccus  P3'ogenes  Aureus,  36 ;  Staph3-lococcus 
P3'ogenes  Citreus,  38  ;  Streptococcus  P3-ogenes, 

38  ;  Streptococcus  Er3-sipelatis,  38  ;  Gonococcus, 

39  ;  Diplococcus  Pneumoniae,  40  ;  Pneumococcus 
Friedlander,  41  ;  Bacillus  Coli  Communis,  41  ; 
Bacillus  P3-oc3'aneus,  42  ;  Bacillus  Tuberculosis, 
42  ;  Bacillus  Tetani,  43  ;  Bacillus  Anthracis,  44  ; 
Bacillus  of  Malignant  CEdema,  44 ;  Bacillus 
Diphtheriae,  45  ;  Bacillus  Prodigiosus,  46  ;  Ac- 
tinom3-ces,  46 ;  Atmospheric  Infection,  48 ; 
Phlogosin,  50  ;  Differentiation  of  Infection,  51 ; 
Classification  of  Diseases  after  Microbes,  51. 

II. — The  Importance  of  Asepsis 53 

Asepsis,  53  ;  Antisepsis,  -.^  ;  Aseptic  Wounds, 
54  ;  Germicidal  Chemical  Substances,  55  ;  Anti- 
septic Solutions,  56  ;  Asepsis  in  Ancient  Times, 
58. 

III. — Means  of  Disinfection 60 

Sunlight,  61  ;  Electricit3-,  61  ;  Mechanical 
Method,  61  ;  Resistance  of  Spores,  62  ;  Heat,  63  ; 
Boiling  Water,  64;  Steam,  64;  Antiseptic  Sub- 
stances, 66  ;  Dr3-ness,  66  ;  Anaerobiosis.  66  ; 
Chemical  Substances,  67  ;  Disinfection  of  Ne- 
crotic Tissue,  68  ;  Artificial  Immunit3-,  7°  :  Phag- 
oc3-tes,  71 ;  Antagonism  of  ^Microbes,  "j^y  ;  Inocu- 
lation with  Septic  Substances,  75  ;  Carbolic 
Acid,  76  ;  Bichloride  of  Mercury^  78  ;  Chloride 
of   Zinc,    80 ;    Salic3'lic    Acid,    81  ;    Aluminum 


10.  COXTEXTS. 

PAGE 

Aceticum.  8i  ;  Peroxide  of  Hydrogen,  82  ;  Pyro- 
zone,  82  ;  lodofonii,  83  ;  Choice  of  Kind  of  Dis- 
infection, 88. 

IV. — Prophylactic  Disinfection 91 

The  Hands  and  Foreanns  of  the  Surgeon,  92  ; 
The  Finger-nails,  92  ;  The  Skin  of  the  Patient, 
95  ;  The  Umbilicus,  97  ;  >Mucous  ]\Iembranes,  97  ; 
The  Vagina,  97  ;  The  Rectum,  98  ;  The  Blad- 
der, 99  ;  The  Urethra,  100  ;  The  Kidne3S,  100  ; 
The  Stomach,  loi  ;  The  Mouth,  loi  ;  The  Nose, 
loi  ;  Soap,  loi  ;  Brush,  102. 

V. — Dl.SINFECTION    OF    INSTRUMENTS  AND    DRESSINGS    IO4 

Mechanical  Disinfection,  104;  Soda-solution,  105; 
Arrangement  of  Instruments  in  the  Sterilizer, 
106  ;  Shape  of  Instruments,  108  ;  Rubber  Cath- 
eters, 109;  Instrument-cases,  no;  Dressing  Ma- 
terial, no;  Pre-heating,  113;  Sterilizers,  113; 
Towels,  Sponges,  Silk,  etc.,  119;  Absorbent 
Gauze,  121  ;  Compressed  Moss,  122 ;  Iodoform 
Gauze,  123  ;  Salic3dated  or  Dermatol  Gauze, 
124  ;    Bandages,   124. 

VI.— Sterilization  of  Catgut,  Silk,  etc 125 

Sterilization  of  Catgut,  126  ;  Preser\^ation  of  Cat- 
gut, 128  ;  Unreliability  of  Catgut,  128  ;  Silk, 
133  ;  Preservation  of  Silk,  134  ;  Thread,  135  ; 
Silkworm  Gut,  136  ;  Silver  Wire,  136  ;  Parch- 
ment Sutures,  etc.,  137. 

VII.— Sponges,    Drainage-tubes,    and     Irrigation 

Fluid 137 

Sponges,  137  ;  Gauze,  138;  Drainage-tubes,  139  ; 
Moist  Blood-clot,  142  ;  Irrigation  Fluid,  142. 

VIII. — The  Aseptic  Operating-room 143 

The  Operating-room  of  a  Hospital,  143  ;  Wash- 
basins, 144  ;  Glass  Shelves,  145  ;  Spectators,  145  ; 
Separate  Operating-rooms,  147 ;  Micro-organ- 
isms in  the  Air,  147  ;  The  Operating-room  in 
Private  Practice,  151  ;  Operating-table,  152  ;  In- 
strument-table, 155  ;  Instrument-cabinet,  156  ; 
Irrigators,  156  ;  I'ails,  158  ;  Baths,  158  ;  Wards 
and  Private  Rooms,  158  ;  Halls  and  Floors,  158; 
Beds,  Tables,  and  Chairs,  158;  Mattresses  and 
vSheets,  158. 

IX.— Aseptic  Wounds 159 

Primary  Union,  159;  Necrotic  Tissue,  160; 
Buried     vSutures,     160;     Risks     in     Occluding 


CONTENTS.  II 

PAGE 

Wounds,  i6i  ;  Technique  of  Uniting  Aseptic 
Wounds,  162  ;  Sutures,  Continued,  163  ;  Relax- 
ation-, 164;  Interrupted,  165;  Situation-,  166; 
Silver-wire,  166  ;  Subcutaneous,  167  ;  Prophylac- 
tic, 168  ;  Immobilization,  168 ;  Aseptic  Fever, 
170. 

X. — Infected  Wounds 171 

Difficulties  of  Disinfection,  172  ;  Cellulitis,  or 
Phlegmon,  173  ;  Erysipelas,  173  ;  Septicsemia, 
173  ;  Pyaemia,  174  ;  Differentiation  between  the 
various  forms  of  Suppuration,  174  ;  Symptoms 
of  Infection,  178  ;  Suppuration  of  Stitch-canals, 
181  ;  Superficial  Gangrene,  183  ;  Ways  of  Infec- 
tion, 184. 

XI. — Aseptic  Open-wound  Treatment 186 

Presence  of  Microbes,  188  ;  Irregular  Cavities, 
189  ;  Drainage,  191  ;  Esmarch  Method  of  Con- 
striction, 194  ;  Splints,  195  ;  Partial  Union,  196  ; 
Putrid  Wounds,  197  ;  Access  of  Air,  198  ;  Moist- 
ure, 198  ;  Antiseptics,  190  ;  Immobilization, 
200  ;  The  Sharp  Spoon,  205  ;  Tubercular  Pro- 
cesses, 206  ;  Intestinal  Operations.  207  ;  Opera- 
tions on  the  Liver  or  the  Gall-bladder,  208  ; 
Mikulicz's  Drain,  209  ;  Operations  on  the  Pelvic 
Organs,  210  ;  Hemorrhage  from  the  Venous  Si- 
nuses of  the  Brain,  210 ;  Operations  on  the 
Kidneys,  211  ;  Methodical  Packing,  211  ;  Resec- 
tions, 211  ;  Drainage  in  P3^othorax,  212;  Drain- 
age of  Bladder,  214 

XII. — Renewal  of  Dressings 214 

Removal  of  Stitches,  215  ;  Removal  of  Sutures, 
216  ;  Secondary  Dressing,  218  ;  Secondary  Hem- 
orrhage, 220  ;  Abundant  Discharge,  223  ;  Der- 
matoses, 226  ;  Eczema,  227  ;  Necrosis  of  Wound- 
margins,  230  ;  Cutting  Through  of  the  Sutures, 
231  ;  Ulcers,  232  ;  Cavities,  234  ;  Compound  Frac- 
tures, 235  ;  Pain,  236  ;  Temperature,  236  ;  Re- 
dressing, 237  ;  Routine  in  HOvSpital  Practice, 
238. 

XIII. — Technique  of  an  Aseptic  Operation  ....  239 
Baths,  239  ;  Assistants  and  Nurses,  240  ;  Steril- 
ized Suits,  etc.,  241  ;  Sterilizing  the  Dressings, 
Instruments,  etc.,  243  ;  Anaesthetizing  the  Pa- 
tient, 246  ;  Procedures  Before  an  Operation,  249 ; 
Procedures  During  an  Operation,  250 ;  Proced- 
ures After  an  Operation,  252. 


12  COXTEXTS. 

PAGE 

XIV. — Aseptic  I^7ECTION 253 

Preparations  before  Injection,  z^t,  ;  Morphine, 
253  ;  Sterility  of  Solutions,  255  ;  Iodoform,  255  ; 
Emulsions,  256 ;  Tuberculocidal  Influence  of 
Iodoform  Injections,  257  ;  Artificial  H^'pertemia 
as  an  Adjuvant,  25S  ;  Irrigation  Trocar,  259  ; 
Ethereal  Solutions,  262  ;  Intraperitoneal  Injec- 
tion, 265  ;  Sterilization  of  Syringes,  265  ;  Aseptic 
Syringe,  267. 

XV. — An.esthesia 268 

Discover}'  of  the  Anaesthetic  Properties  of  Sul- 
phuric Ether,  268  ;  Choice  of  an  Anaesthetic, 
270  ;  The  Inhaler,  271  ;  Rules  to  be  Observed  in 
Anaesthesia,  272  ;  Accidents  during  Anaesthesia, 
276  ;  Deaths  during  Anaesthesia,  277  ;  Artificial 
Respiration,  279  ;  Local  Anaesthesia,  282  ;  Hy- 
drochlorate  of  Cocaine,  283. 

XVI.— Asepsis  in  Private  Practice 284 

Criticisms,  285 ;  Ignorance  of  Aseptic  Rules, 
288  ;  Instruments,  290  ;  Instrument-cases,  291  ; 
Sterilizer,  Dressing-material,  Sponges,  etc.,  291  ; 
Brushes,  Ligatures,  etc.,  292  ;  The  Operating- 
room,  293  ;  Tables,  Chairs,  etc.,  294  ;  Anaesthe- 
sia, 295  ;  Disinfection  of  the  Field  of  Operation, 

296  ;  Importance  of  Asepsis  in  Office  Practice, 

297  ;  Instruction  of  the  Public,  298. 

Index 301 


INTRODUCTION. 


With  the  dawn  of  Antisepsis  there  burst  upon 
the  surgical  world  the  beginning  of  a  new  light 
— a  new  era  was   given  to  surgery. 

When  a  student  in  Berlin  in  1876,  the  writer 
one  day  heard  his  revered  teacher,  Von  Lan- 
genbeck,  say :  "  A  new  method  has  been  ad- 
vanced by  an  English  surgeon  who  predicates 
the  principle  of  wound-treatment  upon  the  de- 
struction of  organic  germs,  which  he  assumes  to 
be  the  cause  of  wound  disturbances.  The  ex- 
cellent results  claimed  by  him  are  not  in  accord 
with  those  we  obtain,  hence  I  can  hardly  grasp 
their  perfection  ;  yet,  notwithstanding  my  expe- 
rience, I  feel  it  incumbent  upon  me  to  test  them 
in  practice."  The  old  master,  then  reputed 
throughout  the  world  as  the  father  of  joint-resec- 
tion, did  not  hesitate  to  become  practically  the 
pupil  of  young  Richard  von  Volkmann,  chief  of 
the  Halle  Surgical  Clinic,  who  had  just  returned 
from  London,  havino-  there  studied  the  methods 
of  Joseph  Lister.  Von  Langenbeck  was  soon 
convinced  that  Listerism  was  not  a  phantasm. 

The    curse  of  centuries    was    ended.     While, 

13 


14  INTRODUCTION. 

before  antisepsis.  So  per  cent,  of  all  wounds 
treated  at  the  University  Clinic  at  Munich  were 
affected  with  hospital  gangrene,  this  disease  was 
now  looked  upon  by  the  students  as  a  rarity. 
Formerly,  the  mortality  from  amputations  reached 
even  60  per  cent. ;  thenceforth  deaths  directly 
traceable  to  amputations  were   the  exception. 

To  the  perspicacity  of  those  ''  to  the  manor 
born,"  and  to  those  who  have  made  America 
their  home,  is  due  the  powerful  impetus  given  to 
the  dissemination  of  this  new  surgical  discovery. 
Arpad  G.  Gerster,  in  his  excellent  work,  was  the 
first  to  bring  Listerism  to  the  front  in  the  United 
States.  The  vast  benefits  it  conferred  were 
quickly  appreciated  in  branches  of  our  profes- 
sion other  than  that  of  surgery.  Closely  follow- 
ing the  vanguard  was  midwifery,  into  which  im- 
portant branch  of  practice  antiseptic  surgical  prin- 
ciples were  soon  introduced,  for  which  Henry  J. 
Garrigues  deserves  special  credit. 

Notwithstanding  its  unequivocal  results,  the 
progressive  tendency  of  surgery  did  not  permit 
Listerism  to  rest  upon  its  achievements.  The 
first  forward  step  naturally  was  directed  toward 
simplifying  its  complicated  methods.  This  ad- 
vance movement  was  primarily  manifested  in 
the  decadence  of  the  '*  spray."  The  bacterio- 
logical investigations,  in  1 881-1888,  of  Robert 
Koch,   especially    his    discovery    that    the    atmo- 


INTRODUCTION.  1 5 

spheric  microbes  are  mainly  of  an  innocuous 
character,  led  to  the  conviction  that  infection 
was  essentially  established  by  contact.  The 
recognition  of  this  fact  gave  birth  to  Asepsis,  as 
a  conscientious  method  whose  advent  saved 
wounds  from  further  contact  with  toxic  sub- 
stances, such  as  carbolic  acid  and  mercuric  bi- 
chloride. Wounds  were  found  to  heal  without 
reaction,  as  the  protoplasm  in  them  was  no 
longer  impaired  by  poisons.  Skull  and  abdo- 
men were  now  opened  without  thought  of  dan- 
ger. In  the  University  Hospital  of  Munich,  asep- 
sis reduced  the  death-rate  in  amputations  to  2 
per  cent.,  while  in  1876,  the  period  of  early  Lis- 
terism,  the  death-rate  still  was  16.1  per  cent.  The 
mortality  from  ovariotomy  has  fallen  from  more 
than  50  to  less  than  10  per  cent.  A  similar 
story  might  be  told  as  to  compound  fractures, 
resections  of  joints,  extirpatio  uteri,  laparot- 
omies, etc.  Amputation  of  the  mammae,  an  ope- 
ration that  formerly  required  from  four  to  six 
months  for  perfect  recovery,  now  needed  but 
two  weeks.  Kocher  during  early  Listerism  had 
nine  deaths  in  12  resections  of  the  intestines; 
his  later  records,  covering  operations  made  asep- 
tically,  show  but  two  deaths  in  13  cases.  But 
it  was  not  surgery  alone  that  was  benefited  by 
asepsis :  the  same  strides  were  made  in  mid- 
wifery, as  shown  by  Von  Ramdohr's  reports  of 


1 6  INTR  OD  UC7I0N. 

400  births,  without  a  single  death,  at  the  New 
York  Post-Graduate  Lying-in  Asylum. 

The  writer  freely  confesses  that  notwithstand- 
ing he  at  first  had  some  doubts  reeardine  the 
reported  results  obtained  by  asepsis  in  Germany, 
yet  he  deemed  it  expedient  to  visit,  in  1891, 
among  others  the  clinics  of  Von  Bergmann, 
Czerny,  Schede,  and  Korte.  The  results  there 
observed  were  so  strikinor  that  he  was  induced 
to  recross  the  ocean  twice  afterward  to  perfect 
himself  in  this  inestimable  art,  a  detailed  descrip- 
tion of  which  is  given  in  the  following  pages. 

The  views  and  methods  described  in  this  vol- 
ume will  undoubtedly  change  within  the  next 
few  years,  the  enormous  rush  of  advancing 
knowledge  relegating  to  the  past  for  the  most 
part  that  which  to-day  is  considered  incontro- 
vertible. "  Tempora  mutantur  et  nos  mutamur 
in  illis"  will  doubtless  apply  to  asepsis  no  less 
than  it  did  to  antisepsis.  However,  one  thing 
is  sure:  the  time  of  "inspiration"  is  over.  The 
principles  upon  which  aseptic  surgery  is  estab- 
lished are  firm,  since  the  theories  which  have  led 
the  technique  to  its  present  state  of  perfection  are 
confirmed  by  bacteriological  tests.  This  change, 
however,  cannot  disturb  the  glorious  foundation 
laid  by  Joseph  Lister.  To  Lister  we  owe  the 
mother,  A^itisepsis,  who,  though  she  died  in  par- 
turition, brought  forth  her  idealization,  Asepsis. 


SURGICAL    ASEPSIS. 


I.    INFLUENCE   OF   MICROBES. 

Sepsis  (pri^iQ,,  putrefaction)  is  due  to  the  en- 
trance and  multiplication  of  microbes  in  an 
organism.  Asepsis  prevents  their  admission  into 
the  human  body.  To  prevent  this  admission 
there  is  requisite  a  series  of  procedures,  the 
mastering  of  which  presupposes  a  perfect  know- 
ledge of  the  characteristics  of  microbes.  Ene- 
mies can  be  combated  successfully  only  when  their 
powers  and  peculiarities  are  well  known. 

The  significance  of  man's  most  virulent  ene- 
mies, the  very  minute  organisms  called  micro- 
organisms, warrants  detailed  consideration  of 
their  powerful  and  peculiar  influence  upon  the 
living  organism.  Generally,  four  classes  of  mi- 
cro-organisms are  recognized:  (i)  The  fungi  or 
moulds  (Fig.  i);  (2)  the  sprouting  or  yeast  fungi 
(saccharomycetes,  blastomycetes)  ;  (3)  the  fis- 
sion fungi,  bacteria  (schizomycetes) — microbes 
noft    e^o^yjv ;    and    (4)    mycetozoa  and  protozoa. 

All   dead   organic   substances   in   contact  with 

2  17 


i8 


SURGICAL   ASEPSIS. 


the  atmosphere  undergo  decomposition,  or  rather 
fermentation,  leading  to  putrefaction,  which  is 
favored  by  the  combined  influences  of  moisture 
and  warmth.  Putrefaction,  as  proved  by  Th. 
Schwann,  is  produced  under  the  influence  of 
micro-organisms  which  are  everywhere  present 
and  everywhere  adherent.  Their  vitahty  is  mar- 
vellous. They  belong  to  the  lowest  class  of  the 
vegetable  kingdom,  and  are  closely  allied  to  the 
fungi  (Fig.  i).  Botanists  term  them  ''schizomy- 
cetes."  These  micro-organisms  and  their  deriva- 
tives are  not  only  established  in 
any  dead  organic  substratum, 
but  they  also,  to  quote  Billroth, 
under  favorable  circumstances 
multiply  most  rapidly  by  caus- 
ing decomposition  of  the  or- 
ganic substance  of  their  foster- 
ing soil,  and  thereby  stir  up  a 
series  of  chemical  processes 
w\\\c\\  Jinally  lead  to  division  of 
Fig.  I.— Fungi  (Penicii-  //^^^^  complicated  covibinatio7is  in- 

lium  glaucum).  .         ,  ^,,  .  .  ^ 

to  stniplc7^  ones.  1  his  action  oi 
these  exciters  of  decomposition  was  designated 
''fermentation."  Their  effect,  unfortunately,  is  not 
dependent  primarily  upon  their  quantity,  which, 
under  favorable  circumstances,  may  be  very  small, 
but  by  constant  reproduction  they  may  so  rapidly 
increase  as  to  cause-decomposition  until  the  soil 


INFLUENCE    OF  MICROBES.  1 9 

that  harbors  them  becomes  exhausted.  The 
rapidity  with  which  microbes  multiply  is  well 
illustrated  by  Cohn.  He  found  that  a  single 
microbe  divides  into  two  within  an  hour,  and 
subdivides  into  four  at  the  end  of  another  hour 
(^Frontispiece,  Fig.  i).  Thus  the  number  derived 
from  a  single  microbe  will  amount  to  16,500,000 
in  twenty- four  hours. 

Pasteur  classified  the  microbes  under  the  so- 
called  "  organic  ferments,"  to 
which  also  belongs  the  yeast 
fungus  (Fig.  2).  To  induce  fer- 
mentation it  w^ould  suffice  that 
the  air,  or  any  solid,  or  a  liquid, 
containinor  such  microbes,  comes 

.       Fig.  2. — Yeast  fungi. 

m  contact  with  a  dead  organic 
substance,  the  fermentation  ceasing  only  when 
the  microbes  have  consumed  all  the  material 
required  to  keep  them  alive.  But,  as  will  soon 
be  seen,  microbes  can  just  as  well  settle  in  other 
than  a  dead  organic  substance.  The  atmosphere 
has  been  regarded  as  an  important  carrier  of 
these  organisms.  The  microbes,  suspended  in 
the  air,  settle  in  solid  and  in  liquid  bodies,  and 
their  vitality  is  destroyed  only  by  a  temperature 
of  212°  F.  (100°  C).  The  conditions  of  their  in- 
vasion into  the  interior  of  the  livine  organism 
are  furnished  by  a  break  in  the  continuity  of  the 
skin   or   in   the   mucous   membranes ;    while   the 


20  SURGICAL   ASEPSIS. 

conditions  for  the  development  and  multiplica- 
tion of  the  microbe  that  has  invaded  or  has  been 
brought  into  the  organism  prevail  wherever  there 
is  a  favorable  soil.  Microbes  grow  best  in  a 
temperature  varying  from  86°  to  98°  F. 

Fully  thirty  years  ago,  Pasteur  and  Billroth 
recoofnized  the  decided  influence  of  micro-oro-an- 
isms  upon  wounds  and  inflammatory  processes. 
Lister  carried  these  theoretical  investioations 
into  practice.  After  many  erroneous  views  were 
corrected,  Robert  Koch  succeeded  in  isolating  cer- 
tain forms  from  the  enormous  quantity  of  micro- 
organisms known,  and  in  cultivating  them  sepa- 
rately on  artificial  soil.  Thus  it  became  possible 
to  study  their  influence  upon  living  tissues,  and 
to  demonstrate  their  presence  therein  by  charac- 
teristic reactions  made  evident  by  staining.  It 
was  discovered  not  only  that  fermentation  in 
dead  substances  was  caused  by  organic  germs, 
but  also  that  a  whole  series  of  pathological  pro- 
cesses in  the  living  organism,  locally  as  well  as 
generally,  were  due  to  invasion  and  multiplica- 
tion of  specific  microbes.  While  the  ferment 
germs  were  formerly  regarded  as  the  cause  of 
the  peculiar  complications  in  wounds  and  in  in- 
flammatory processes  called  "accidental  wound- 
diseases,"  it  is  now  a  well-established  fact  that, 
besides  these  germs  many  varieties  of  micro- 
orofanisms  exist  which  have   no   connection  with 


INFLUENCE    OF  MICROBES.  21 

fermentation,  but  which  cause  a  decided  influence 
upon  the  Hving  organism. 

It  has  been  proved  that  certain  species  of 
microbes  cause  inflammation,  that  other  species 
cause  suppuration  or  gangrene,  and  that  the 
most  serious  compHcations  in  connection  with 
wounds  and  inflammatory  processes — that  is, 
the  most  frequent  and  deleterious  acute  and 
chronic  diseases — are  due  solely  to  microbic 
infection.  Microbes,  according  to  the  conditions 
essential  to  their  life,  are  of  two  kinds  : 

(i)  Pathogenous  or  parasitic  microbes,  which 
develop  and  multiply  only  within  living  organ- 
isms. 

(2)  Saprophytes  or  nonpathogenous  microbes, 
which  depend  upon  nutriment  obtained  within 
dead  tissue. 

The  pathogenous  microbes  are  either  {a)  facul- 
tative (occasional),  depending  but  partially  upon 
nutriment  obtained  within  living  organisms,  or 
[b)  obligate  (real),  which  entirely  depend  for  their 
existence  upon  the  soil  found  within  living  animal 
organisms.  Only  some  of  the  obligate  parasites 
can  be  cultivated  on  artificial  soil. 

The  action  of  these  parasites  is  not  the 
same  in  all  species  of  animals.  One  kind  of 
micro-organism  may  produce  intense  specific 
effects  in  one  species  of  animal,  for  which  it 
may  be  pathogenic,  while   upon   another  it  may 


22  SURGICAL    ASEPSIS. 

not  exert  the  slightest  influence.  The  so-called 
''saprophytes"  have  no  influence  whatever  upon 
living  human  tissue,  but  they  may  do  consider- 
able harm  bv  settlins:  in  necrotic  tissues  and  in 
exudations. 

The   saprophytes    should   not   be    confounded 
with    the    pathogenic    microbes,  which    produce 
specific    processes    wdthin    living    tissue.       The 
latter    micro-organisms    appear    in    three    w^ell- 
characterized  forms— ^namely:  (i)  The 
.*.  •* •*.       micrococcus  [(itxpog,  small ;  6  xoxxog,  the 
**•'/':       kernel)    or   coccus,  which    presents    a 
Fig.  3.-Cocci.  spherical  form   (Fig.  3) ;    (2)  the  bac- 
termm  (ro  (BaxTy^piov,  rod) — in   the  re- 
stricted sense   of    the  word — or  bacillus  (a  little 
rod    or    staff),    or    staff-shaped    micro-organism 


'^^ 


3 


..>■■ 


Fig.  4.— Bacilli.  Fig.  5.— Spirillum 

(relapsing  fever). 

(Fig.  4)  ;  and  (3)  the  spirillum  (amtpfx,  a  coil),  or 
spiral-shaped  micro-organism,  which  has  the  ap- 
pearance of  a  spirally-twisted  thread  (vibrio,  spiro- 
chaite  ;  Fig.  5j.   lliese  expressions  do  not  indicate 


INFLUENCE    OF  MICROBES.  23 

a  decided  species,  but  denote  only  the  morpho- 
logical character  of  micro-organisms,  the  different 
forms  of  which  can  be  compared  best  with  (i) 
a  billiard-ball,  (2)  a  lead-pencil,  and  (3)  a  cork- 
screw. Their  better  comprehension  demands 
qualification,  such  as  micrococcus  pyogenes,  bacil- 
lus antlu^acis,  etc.  It  is  customary  now  to  use 
the  term  "bacterium"  synonymously  with  "mi- 
crobe," and  not  with  "bacillus,"  which  would  be 
the  "bacterium  xojr  I'^oj/iv!' 

The  cells  of  the  microbes  present  two  essen- 
tial parts — namely,  the  nucleus,  and  the  surround- 


FiG.  6. — Streptococci.  Fig.  7. — Coccoglia. 

inor  membrane  called  the  "cell-membrane" — both 
of  them  beinor  enclosed  in  a  orelatlnous  cover. 
The  substance  of  the  nucleus  consists  of  proto- 
plasm, w^hich  has  the  peculiarity  that  it  can  be 
stained  by  aniline  dyes,  while  the  elastic  mem- 
brane is  composed  of  a  substance  closely  related 
to  cellulose.  The  membrane  is  distinguished  by 
its  peculiarity  of  swelling  in  water. 

Cocci  and  bacilli  are  either  Isolated  or  adherent 
to  each  other,  or  they  form  chains  of  from  four 


24 


SURGICAL   ASEPSIS. 


to  twenty  or  more  rows  (streptococcus,  strepto- 
bacterium,  from  6  Qn^iitrbq,  the  chain  ;  Fig.  6), 
or  tliev  are  acro-lomerated  in  irregular  olobular 
and  cyhndrical  forms  by  masses  of  mucus 
(coccogHa,  Yi  y?aa  or  y?.0La,  the  glue  ;  Fig.  7)  ex- 
creted by  themselves  (staphylococcus,  ascococcus). 
The  globular  elements  differ  markedly  in  size. 


Fig.  8. — Flagellate  bacilli  (typhoid). 

They  are  sometimes  as  large  as  a  cell-nucleus, 
or  they  are  equal  to  the  diameter  of  a  globule 
which  can  barely  be  perceived  by  the  strongest 
magnifying  power.  They  are  sometimes  mov- 
able, sometimes  quiescent. 

The  bacilli  are  of  various  lengths.     Some  are  so 
short  that  they  might  be  mistaken  for  cocci ;  the 


INFLUENCE    OF  MICROBES.  2$ 

longest  ones  equal  20^^  in  length.  Their  thick- 
ness is  very  irregular.  Some  forms  show  lively 
motion  in  the  "  migratory  stage,"  induced  by 
their  flagella,  or  thread-like  appendages  (Fig.  8). 

Most  species  of  micro-organisms  grow  only  as 
cocci,  bacilli,  or  spirilli.  Besides  these  species 
there  are  others  which  vary  widely  in  form  during 
their  development.  In  the  quiescent  state  the  or- 
ganisms either  remain  isolated  or  they  unite  into 
so-called  "colonies"  (zoogloea,  Frontispiece,V\g.  2) 
showing  peculiarities  that  are  very  important 
in  differentiating  the  species.  Multiplication  of 
micro-organisms  takes  place  either  by  division — 
that  is,  one  cell  splits  into  two  or  more  similar 
ones — or  by  the  formation  of  spores. 

As  stated  before,  micro-oro^anisms  are  found 
as  well  in  foul  or  fermentinor  substances  as 
in  the  living  organism.  But  they  prosper  only 
under  the  following  conditions:  i,  they  re- 
quire water  in  large  quantities ;  2,  they  need 
nitrogenous  combinations  for  their  assimilation  ; 
3,  they  must  have  a  comparatively  high  tem- 
perature (the  most  favorable  temperature  being 
that  of  the  blood).  They  separate  the  complicated 
organic  constituents  of  their  fostering  soil  into  a 
series  of  much  simpler  substances,  during  which 
process  CO2  is  formed  and  warmth  is  evolved. 
This  transformation  is  due  to  the  action  of  the 
living  protoplasm  of  the  micro-organisms,  which 


26  SURGICAL  ASEPSIS. 

substance  probably,  like  a  ferment,  Is  able  to 
seereeate  a  ereat  amount  of  suitable  soil.  The 
products  of  this  change  of  matter  are  numerous 
and  are  but  partially  known.  They  change  fre- 
quently, according  to  the  form  of  the  microbe  and 
the  character  of  the  soil  offered.  Most  fre- 
quently hydrosulphuric  acid,  carbonic  acid,  car- 
buretted-hydrogen  gas,  hydrogen,  ammonia, 
water,  alcohol,  citric  acid,  aromatics  (phenol, 
tyrosin),  and  peptones  are  formed.  In  addition, 
many  microbes  produce  ferments ;  others — and 
surgically  they  are  the  most  important — form 
different  substances,  known  as  ptomaines  (tox- 
ines,  toxalbumins,  cadaver-alkaloids,  leucomaines), 
which  exercise  a  virulent  influence  upon  the  liv- 
ing organism.  These  toxic  products  were  detected 
first  in  foul  liquids  and  then  in  decomposing  hu- 
man cadavers.  They  are  bases  containing  nitro- 
gen ;  they  very  much  resemble  vegetable  alka- 
loids ;  they  are  in  part  products  of  tissue-meta- 
morphosis in  microbes  ;  but  it  is  now  known  that 
they  are  especially  produced  by  microbes  within 
living  tissues.  Bergmann  and  Zuelzer  obtained 
virulent  extracts  from  decomposing  mixtures, 
and  Brieger  and  Nencki,  who  produced  a  whole 
series  of  ptomaines,  ascertained  the  combination 
of  their  chemical  elements.  Thus  are  known 
some  indifferent  and  some  virulent  alkaloids 
which  originate  in    the    human    cadaver,   begin- 


INFLUENCE    OF  MICROBES.  2 7 

ning  on  the  third  day  after  death.  Further- 
more, it  is  known  that  some  alkaloids  are  formed 
by  specific  pathogenic  microbes.  A  knowledge 
of  the  chemical  substances  produced  by  various 
forms  of  microbes  in  their  cultures  is  of  the 
most  vital  importance,  as  in  most  instances  local 
as  well  as  general  effects  depend  upon  them. 
Whenever  necrotic  tissue  or  a  fluid — for  instance, 
a  bloody  effusion — is  present  in  a  living  organ- 
ism, microbes  may  develop,  while  the  healthy 
physiological  tissues  remain  very  resistant. 

According  to  Pasteur,  microbes  should  be  di- 
vided into  ah'obic,  those  which  live  best  in  oxygen, 
and  anaerobic,  those  which  not  only  live  without, 
but  generally  die  in,  pure  oxygen.  Both  forms 
produce  decomposition.  When  an  organic  fluid 
is  exposed  to  the  free  atmosphere,  it  becomes 
turbid,  because  the  microbes  w^hich  fall  into  it 
from  the  air  rapidly  multiply ;  a  priori  only  the 
aerobic  microbes  do  so.  They  quickly  consume 
all  the  oxygen  contained  in  the  liquid,  and  as  soon 
as  they  have  accomplished  this  they  must  die  and 
settle  to  the  bottom  of  the  liquid  in  the  shape  of 
a  muddy  sediment.  Some  may  continue  to  live 
on  the  surface  of  the  fluid,  where  thev  obtain 
partial  nourishment  from  the  atmosphere,  and 
where  they  form  a  membrane  which  gradually 
thickens  and  prevents  access  of  oxygen  to  the 
liquid  and  to  the  organisms  held  in  suspension. 


28  SURGICAL  ASEPSIS. 

Then  the  opportunity  arises  for  the  anaerobic 
microbes  [luicrobes  de  la  putrefaction,  Pasteur) 
to  cause  a  transformation  of  the  combinations 
of  nitrogen  into  much  more  compHcated  sub- 
stances. These  substances  ao^ain  are  so  de- 
composed  by  the  aerobic  microbes  that  they 
attract  oxygen,  and  while  decomposition  pro- 
gresses further  the  united  action  of  anaerobic 
and  aerobic  microbes  finally  liberates  the  last 
products  of  decomposition — namely,  water,  car- 
bonic acid,  and  ammonia. 

Some  micro-ororanisms  are  found  in  so-called 
"putrid  processes,"  while  others  occur  in  tissues 
and  in  fluids  which  do  not  show  the  slig^htest 
trace  of  decomposition — for  instance,  in  abscesses 
which  have  not  been  exposed  to  the  atmosphere 
at  all.  Hence  it  must  be  assumed  that  the  real 
decomposing  microbes  cause  only  a  part  of  those 
changes  which  are  ordinarily  considered  the  con- 
sequence of  infection.  As  shown  before,  it  is 
necessary  to  distinguish  between  real  sapro- 
phytes and  microbes  xar'  i.^oyyiv — that  is,  be- 
tween septogenic  and  pathogenic  organisms — 
although  this  distinction  is  only  relative.  While 
saprophytes  which  will  settle  on  wound-surfaces 
and  in  cavities,  as  in  the  necrotic  endometrium  of 
a  puerperal  uterus  or  in  the  intestines,  originate 
ptomaines,  the  absorption  of  which  would  be  fol- 
lowed  by  toxic  effects  upon  the  living  organism, 


INFLUENCE    OF  MICROBES. 


29 


the  pathogenic  microbes  find  the  most  favorable 
conditions  for  their  development  and  multiplica- 
tion in  living  tissue — that  is,  inside  of  cells,  in  the 
blood,  in  the  lymphatics,  etc.  By  thus  invading 
the  system  they  cause  a  series  of  disturbances. 
These  pathogenic  microbes  differ  essentially  from 
the  decomposing  micro-organisms,  and  are  killed 
by  them  in  dead  tissue.  Hence  decomposition, 
strange  to  say,  is  itself  the  most  effective  anti- 
parasitic agent  to  overcome  the  action  of  such 
microbes. 


Fig.  9. — Staining  the  bacillus  tuberculosis. 

No  scientific  method  of  isolating  and  cultivat- 
ing  a  distinct  species  from  a  mixture  of  these 
different  microbes  was  known  until  Robert  Koch 
discovered  the  mode  of  disseminating  a  mixture 
of  them  over  a  laro-e  surface  in  order  to  favor 
the  development  of  the  various  species.  Then 
the  different  forms  of  vegetation  could  be  recoe- 
nized  with  the  naked  eye  as  spots  or  turfs  of  a 
peculiar  shape,  color,  growing  species,  etc.    On  an 


30 


SURGICAL   ASEPSIS. 


artificially  prepared  soil,  especially  on  gelatin  or 
on  agar,  pure  cultures  can  readily  be  obtained. 
Some  of  them  are  characterized  by  their  capacity 
to  liquefy  the  gelatin,  while  others  form  white 
dry  heaps  or  white  mucilaginous  drops,  or  form 
colonies  of  a  yellow,  green,  or  red  color. 

A  very  important  aid  in  distinguishing  these 
different  forms  under  the  microscope  is  their 
staining  (Fig.  9)  with  certain  coloring  matters,  es- 
pecially aniline  dyes,  and  the  so-called  "  Abbe's 
illumination,"  a  method  which  allows  a  distinct 


Fig.  10. — Making  gelatin  cultures. 

ocular  perception  of  the  stained  microbes.  Koch's 
investigations  are  based  upon  the  necessity  of 
cultivating  these  species  pure ;  that  is,  they  must 
be  free  from  all  accidental  admixtures.  In  order 
to  obtain  this  purity  in  cultivation  a  small  quan- 
tity of  the  substance  containing  the  microbes 
is  implanted  upon  some  suitable  liquid  soil,  meat 
or  agar-agar  gelatin,  to  which  peptone  is  added, 
being  generally  preferred  (Fig.  10).   Hie  soil  must 


INFLUENCE    OF  MICROBES. 


31 


first  be  freed  from  all  foreign  microbes — that  is, 
it  must  be  sterilized — and  then  the  cultivation  must 
be  conducted  in  an  incubator  (Fig.  11).     From 


Fig.  II. — Incubator. 


Fig.  12. — Puncture  culture  (</); 
linear  culture  {b). 


the  first  culture  a  second,  and  from  the  second  a 
third,  is  made,  and  so  on  until  a  whole  series  of 
cultures  always  produces  the  same  micro-organ- 
isms, and  no  others  (Fig.  13)  ;  from  the  last  pure 


32 


SURGICAL   ASEPSIS. 


culture  a  lower  animal  is  then  inoculated.  If  strict 
precautions  are  observed,  the  special  microbes 
alo?ie  are  transferred  (Fig.  15).   Cultures  are  made 


Fig.  13. — Diluting  cultures. 


either  by  means  of  the  "hanging  drop,"  that  is, 
by  placing  a  drop  of  the  sterilized  nutritive  liquid, 
with  the  aid  of  a  sterilized  platinum  wire,  upon  a 


Ik;.  14.  — I'ounding  plates. 


Sterilized  cover-glass  to  which  a  small  quantity  of 
the  culture  is  added ;  or  the  nutritive  gelatin, 
after  being  mixed  with  the  cultures  and  being 
liquefied  in  a  test-tube,  is  poured  on    sterilized 


INFLUENCE    OF  MICROBES.  33 

glass  plates  (Petri's  plates;  Fig.  14),  where  the 
microbes  will  grow  within  a  day  or  two. 

Of  especial  importance  are  the  needle-punc- 
tures or  needle-point  cultures  (Fig.  12,  a)  and 
the  linear  cultures  (Fig.  12,  b).  The  first  are 
obtained  by  bringing  a  platinum  wire  into  con- 
tact with  a  particular  colony  and  then  plunging 
it  into  gelatin  which  has  been  put  into  a  test-tube, 
the  cultures  appearing  in  the  area  of  the  punc- 
ture obtained  by  drawing  the  wire  lightly  over 
the  surface  of  the  hardened  gelatin. 

If  certain  pathological  changes  make  their  ap- 
pearance in  the  test-animals,  these  changes  must 
be  proven  to  have  been  caused  entirely  by  mul- 
tiplication of  the  inoculated  microbes.  Further- 
mx)re,  the  cultivation  of  one  specimen  of  microbe 
taken  from  the  inoculated  animal  must  produce 
the  same  micro-organism  which  had  been  cul- 
tivated at  first.  Only  when  such  experiments  are 
frequendy  repeated  with  the  same  result  is  it 
established  that  the  specific  micro-organism  of  a 
disease  is  discovered. 

It  would  lead  too  far  to  describe  the  technique 
of  the  investigation  as  well  as  of  the  cultivadon 
of  these  micro-organisms,  as  it  is  only  possible 
to  become  acquainted  with  these  methods  by 
thorough  study,  without  which  no  surgeon  can 
succeed.  As  the  surgeon  of  the  present  day  is 
not  justified  in  performing  nephrectomy  without 


34 


SURGICAL  ASEPSIS. 


having  a  thorough  knowledge  of  the  pathological 
changes  In  the  kidneys  and  of  the  microscopical 
examination  of  the  urine,  so,  If  unacquainted  with 
the  characteristics  of  the  origin  of  sepsis,  he  will 
have  no  thorough  understanding  of  the  vital  im- 
portance of  aseptic  principles. 


Fig.  15. — Inoculating  a  mouse. 

The  primary  Influence  of  a  pure  culture  upon 
the  living  tissues  Is  at  first  mechanical,  caused 
by  rapid  multiplication  and  distribution  of  the 
colony.  This  influence  depends  not  only  upon 
the  vitality  of  the  culture,  but  is  determined  also 
by  the  character  of  the  tissue.  The  secondary 
influence  is  due  to  those  peculiar  effects  caused 
by  the  chemical  products  of  the  tissue-metamor- 
phosis of  the  micro-organisms,  which  show  their 
effects  first  locally  and  then  generally,  by  Intoxi- 
cating the  whole  system. 


INFLUENCE   OF  MICROBES.  35 

These  substances,  the  "  toxines,"  after  being" 
absorbed,  produce  an  effect  whose  intensity 
depends  upon  the  degree  of  their  reproduction. 
Microbes  are  found  in  all  inflammatory  processes 
where  suppuration  takes  place.  It  is  not  the 
presence  alone  of  these  so-called  "  pyogenous  mi- 
crobes" that  causes  suppuration,  but  it  is  also  the 
presence  of  the  chemical  substances  which  are 
partially  evolved  in  them  or  which  are  produced 
by  their  soil ;  therefore  the  pathological  changes 
differ  according  to  that  soil.  Thus,  large  quanti- 
ties of  pyogenous  micro-organisms  may  be  ab- 
sorbed without  any  harm  to  the  system,  if  only 
the  accumulation  of  the  products  of  their  tissue- 
metamorphosis  is  prevented  ;  while  the  presence 
of  any  quantity  of  these  products  in  the  tissues 
invariably  causes  suppuration. 

An  important  factor  in  suppuration  is  the  prop- 
erty called  ''  chemotaxis,"  which  means  the  capac- 
ity of  vegetable  as  well  as  of  animal  cells  of 
being  attracted  by  certain  chemical  substances. 
One  of  these  substances  is  obtained,  for  instance, 
by  sterilized  cultures  of  the  staphylococcus 
aureus,  one  of  the  most  frequent  pyogenous 
organisms.  Leber  called  this  particular  substance 
"phlogosin."  But  the  same  capacity  pertains  to 
a  series  of  chemical  substances,  inorganic  as  well 
as  organic  ;  as,  for  instance,  mercury,  nitrate  of 
silver,  turpendne,  etc.,  which,  when   sterilized — 


36  SURGICAL   ASEPSIS. 

that  Is,  freed  from  micro-organisms — produce  sup- 
puration ;  but  pus  of  this  kind  contains  no  micro- 
organisms. The  importance  of  micro-organisms 
is  shown  by  the  fact  that  by  constantly  influencing 
the  soil  they  reproduce  pyogenic  substances,  and 
that  they  progressively  transport  their  own  inde- 
pendent vegetation  from  its  original  focus  into 
the  neiorhborinof  tissues.  Althoucrh  it  has  been 
proved  that   suppurative    inflammation    may  be 


.»o»'05^  OQOOOn  a 


Fig.  16. — Streptococci  (Torula). 


produced  by  sterilized  substances,  the  presence 
of  micro-organisms  in  acute  suppurative  pro- 
cesses is  the  rule. 

The  micro-organisms  of  most  importance  from 
a  surgical  standpoint  are  the  pyogenic  cocci. 
Those  which  are  most  frequently  found  in  phleg- 
monous pus  are  the  staphylococcus  pyogenes 
aureus  (Frontispiece,  Fig.  4),  the  staphylococcus 
pyogenes  albus,  and  the  streptococcus  pyogenes 
{Fro7itis piece,  T^ig.  5). 

The  staphylococcus  pyogenes  atu^cus  [Frontis- 
piece,   Fig.    4)    is    found    abundantly  and  nearly 


I'NFLUENCE    OF  MICROBES.  37 

everywhere,  its  favorite  seat  being  the  superficial 
stratum  of  the  skin,  especially  of  moist  parts,  as 
in  the  axillae.  It  is  frequently  found  also  under 
the  finger-nails,  for  which,  quite  unfortunately 
from  a  surgical  standpoint,  It  has  a  particular  pre- 
dilection. It  is  found  in  all  kinds  of  suppurative 
processes,  in  carbuncle,  acute  infectious  osteomy- 
elitis, suppurating  glands,  pyothorax,  tonsillar 
abscesses,  lacunar  angina,  felons,  sycosis,  impetigo, 
and  suppurative  parotitis.  Frequently  it  is  found 
in  such  processes  In  company  with  other  pyoge- 
nous  cocci.  The  staphylococcus  Is  very  resistant 
to  all  kinds  of  chemical  disinfection.  It  stains 
well  in  aqueous  dyes  and  by  Gram's  method. 
Pure  cultures  of  this  highly  Important  microbe 
were  obtained  first  by  Rosenbach.  It  settles  be- 
tween the  tissues  in  grape-like  bunches.  It  grows 
on  all  culture-media  of  the  laboratory,  and  espe- 
cially well  on  potatoes  {^Frontispiece,  Fig.  3).  On 
the  plates  it  forms  round  orange-colored  colonies, 
a  characteristic  feature  of  which  Is  that  they  liquefy 
gelatin.  Numerous  experiments  proved  that 
staphylococci  are  the  true  cause  of  suppurative 
inflammation.  If  they  are  brought  Into  contact  with 
wounds  they  produce  progressive  suppuration. 
They  may  even  enter  through  the  uninjured  skin, 
probably  through  the  follicles  of  the  sebaceous 
glands.  Garre,  by  rubbing  pure  cultures  of  these 
cocci  Into  the  skin  of  his  arm,  produced  a  carbuncle 


38  SURGICAL  ASEPSIS. 

in  the  purulent  discharge  of  which  he  found 
staphylococci.  Animals  can  be  infected  easily  by 
introducing  the  cultures  hypodermatically.  These 
cultures  soon  form  abscesses.  If  staphylococci 
are  taken  up  by  the  circulation,  they  produce 
suppurative  inflammation  of  the  joints,  small  ab- 
scesses, and  metastases  in  the  heart  and  kidneys. 

The  staphylococcus  pyogenes  citreus  {^Fro7itis- 
piecCy  Fig.  3),  first  described  by  Passet,  is  dis- 
tinguished from  other  staphylococci  only  by  the 
lemon-yellow  color  of  the  cultures  it  produces. 
It  is  found  only  in   abscesses. 

The  streptococcus  pyogenes  (Figs.  6,  16)  is  one 
of  the  most  important  varieties  of  the  pyogenic 
cocci.  The  arranorement  of  the  cocci  is  in  rows  or 
in  chains ;  generally  from  six  to  ten  rows  are  at- 
tached to  one  another.  Unlike  the  staphylococci, 
they  grow  in  small  pin-point  colonies,  and  do  not 
liquefy  gelatin.  Their  sites  of  predilection  are 
in  the  secretions  of  the  vagina,  the  urethra,  the 
nose,  and  in  the  saliva.  The  streptococcus 
pyogenes  is  the  cause  of  erysipelas,  endocarditis 
ulcerosa,  grave  polyarthritis,  and  of  spreading 
inflammatory  and  metastatic  processes  (like  post- 
operative peritonitis  and  puerperal  pyaemia,  for 
instance).  It  can  be  stained  witli  aqueous  aniline 
dyes  and  by  the  method  of  Gram. 

The  streptococcus  erysipelatis  (PI.  I.,  Pig.  i)  can- 
not be  distinguished  from  the  preceding  coccus, 


SURGICAL    ASEPSIS. 


Platk  I. 


i 


\      ^ 


If, 


7 


\ 


MicRO-OKGAMSMS.— I.  Streptococci  erysipelati^^,  from  erj-sipelatous  skin.  2.  Gonorrhoea  cocci, 
from  gonorrhoea!  pus.  3.  Tubercle  bacilli  in  phthisical  sputum.  4.  'I'ubercle  bacilli  from  tubercu- 
iar  meningitis.     5.  Tetanus  bacilli  with  spores,  from  agar.     6.   Bacillus  prodigiosus,  from  gelatin. 


INFLUENCE   OF  MICROBES.  39 

and  its  identity  with  it  is  assumed  by  many  investi- 
g-ators.  Fehleisen  succeeded  in  cultivating  the 
streptococci  found  in  erysipelas,  and  reproduced 
typical  erysipelas  by  inoculating  men  with  the 
pure  cultures.  Koch  and  others,  however,  long 
before  had  demonstrated  the  presence  of  mi- 
crobes in  erysipelatous  tissue,  the  margins  and 
lymphatic  vessels  of  which  contai[ied  them  con- 
stantly. Lesions  of  the  skin  most  frequently  rep- 
resent the  avenue  through  which  the  streptococci 
enter.  The  streptococcus  is  a  most  virulent 
microbe  and  has  an  immense  power  of  develop- 
ment— a  very  unfortunate  circumstance  for  a 
surtreon  who  takes  the  risk  of  oroinor  from  a  case 
infected  by  streptococci  directly  to  the  operating- 
room  to  perform  an  abdominal  section. 

The  gonococcus  (PL  I.,  Fig.  2),  discovered  by 
Neisser,  is  found  in  the  purulent  discharge  of 
urethral  and  conjunctival  gonorrhoea.  The  gono- 
cocci  generally  can  be  seen  lying  within  the  pus- 
cells  or  grouped  around  the  kernels  of  the  cells. 
Two  are  usually  attached  to  each  other,  so  that 
they  are  recognized  as  diplococci.  Their  shape 
is  kidney-like.  They  can  be  stained  with  a  simple 
aqueous-alcoholic  solution  of  methylene  blue, 
which  stains  the  cocci  a  dark  blue  color,  while 
the  kernels  of  the  pus-cells  appear  light  blue. 
By  Gram's  method  they  can  be  decolorized. 
Another  valuable  method  of  stainino-  is  that  of 


40  SURGICAL  ASEPSIS. 

treating  preparations  with  a  concentrated  solu- 
tion of  eosin.  Cultivation  of  this  important  mi- 
crobe outside  the  human  body  is  difficult,  and  is 
only  successful  on  blood-serum,  which  can  be 
obtained  from  a  placenta.  The  gonococcus  forms 
a  nearly  colorless  coating  of  small  extent.  Cul- 
tures die  after  three  days.  Bumm,  by  trans- 
ferring cultures  into  the  urethra  of  men,  pro- 
duced typica]  gonorrhoea.  Animals  are  immune 
against  this  coccus,  therefore  it  must  be  assumed 
that  it  is  a  real  human  parasite  which  does  not 
find  a  soil  in  other  organisms.  The  typical  shape 
and  the  situation  within  the  pus-cells  are  valuable 
characteristics  of  the  eonococci,  and  make  their 
recognition  comparatively  easy. 

The  diplococais  pneunionicB,  discovered  by 
Fraenkel  in  the  rusty  sputa  of  patients  affected 
with  pneumonia,  is  supposed  to  be  the  cause  of 
pneumonia.  It  is  an  encapsulated,  lancet-shaped 
microbe.  Besides  its  favorite  seat  in  the  lungs, 
it  is  found  in  meningitis  cerebro-spinalis  epidem- 
ica  (Foa  and  Bordoni),  in  suppurative  otitis  media 
(Weichselbaum),  in  primary  nephritis,  in  endo- 
carditis ulcerosa,  in  pleuritis,  pyothorax,  and 
pericarditis,  and  also  in  the  sputa  of  healthy  indi- 
viduals. Animals  inoculated  with  small  quantities 
of  human  sputum  die  from  the  so-called  "sputum- 
septiccemia."  The  diplococcus  can  be  stained  with 
diluted  alcoholic  dyes,  and  also  by  Gram's  method. 


INFLUENCE    OF  MICROBES.  4 1 

The  pnemnococcus  Friedldnder,  which  ought  to 
be  called  a  bacillus,  as  it  is  of  an  oblong  shape, 
has  also  been  cultivated  by  Friedlander  from  the 
sputa  of  patients  suffering  from  pneumonia.  It 
can  easily  be  distinguished  from  the  former 
coccus,  as  it  does  not  stain  by  Gram's  method. 

Among  the  bacilli,  the  following  are  of  surgical 
interest : 

The  bacillus  coli  communis  (bacterium  coli  com- 
mune) has  been  found  by  Escherich  constantly  in 
the  intestines  of  nursinof  children  ;  this  bacillus 
was  also  found  in  places  where  typhus  fever  was 
endemic.  The  bacillus  is  thin  and  from  0.3-0.4 
micromillimetres  in  length.  It  possesses  little 
power  of  motion.  It  can  be  stained  with  the 
ordinary  dyes,  and  may  be  decolorized  by  the 
method  of  Gram.  On  grelatin  the  colonies  form 
a  thin  superficial  coating  of  a  white  color  and 
with  an  irregular  margin.  They  do  not  liquefy 
gelatin,  nor  do  they  form  spores.  Rabbits  inoc- 
ulated with  this  bacillus  die  one,  two,  or  three 
days  after  hypodermatic  injections  of  the  cultures. 

This  bacillus  is  an  essential  factor  in  suppura- 
tive peritonitis  ;  it  does  not,  however,  appear  to 
be  the  only  cause  of  this  condition.  The  strep- 
tococcus is  frequently  found  in  company  with  it, 
and  Welch's  observation,  that  the  colonies  of  the 
bacillus  coli  communis  grow  so  rapidly  and  exten- 
sively that  the  smaller  ones  of  the  streptococci  are 


42  SURGICAL   ASEPSIS. 

SO  overshadowed  that  they  are  overlooked,  would 
point  to  an  accompanying  excitation  of  inflamma- 
tion by  the  two  microbes. 

The  bacilhis  pyocyancus  is  the  cause  of  the 
green  or  bkie  color  of  dressings  saturated  with 
pus.  This  bacillus,  a  small  slim  rod,  possesses 
considerable  motile  power.  Gessard  isolated 
it  first,  and  Loffler  made  the  observation  that 
one  thread  is  always  attached  to  it.  It  does 
not  contain  spores.  Gelatin,  on  being  liquefied 
through  its  colonies,  assumes  a  green  fluorescent 
color.  On  potatoes  a  yellow-green  coating  can 
be  cultivated,  which  can  be  stained  red  by  acids, 
while  ammonia  stains  it  green-blue,  the  coloring 
matter  thereby  obtained  being  called  "  pyocya- 
nin."  This  bacillus,  which  can  be  stained  with  the 
ordinary  dyes,  is  widely  distributed.  In  hospitals 
true  epidemics  of  blue  pus  have  often  been  ob- 
served. It  is  highly  infectious  for  rabbits,  and 
sometimes  also  for  men.  There  is  no  doubt  that 
it  is  pyogenic  as  well  as  chromogenic. 

The  bacillus  tuber cidosis  (PI.  I.,  Figs.  3,  4)  was 
discovered  by  Robert  Koch,  who  produced  tuber- 
culosis artificially  by  inoculating  animals  with  pure 
cultures.  The  microscopical  test  disclosed  its 
presence  in  all  tubercular  tissue  and  in  tlie  sputa 
of  tuberculous  patients.  More  than  a  hundred 
years  ago,  however,  tuberculosis  was  supposed 
to  be  an  infectious  disease,  and  in  1865  Villemin 


INFLUENCE    OF  MICROBES.  43 

succeeded  in  transferrinor  tubercular  substances 
to  rabbits  and  produced  tuberculosis  in  them. 
A  few  years  later,  Cohnhelm  obtained  the  same 
results  by  inoculating  the  corneae  of  rabbits, 
thereby  proving  tuberculosis  to  be  a  true  infec- 
tious disease.  ' 

The  tubercle  bacillus  is  a  small  slim  rod 
which  possesses  no  power  of  motion.  It  is  easily 
stained  by  the  methods  of  Koch  and  Ehrlich,  and 
by  the  methods  of  Friedlander,  Giinther,  and 
Biedert.  Characteristics  of  the  bacilli  are  their 
power  of  resistance,  their  taking  up  of  dyes,  and 
the  difficulty  of  decolorizing  the  cells.  It  is  the 
cause  of  tuberculosis  of  the  lungs  and  of  lupus. 
There  is  hardly  a  tissue  in  the  body  that  may 
not  become  the  primary  seat  of  tuberculosis, 
(This  primary  seat  is  often  overlooked  after  the 
tubercular  process  has  spread.)  If  it  is  borne 
in  mind  that  at  least  one-seventh  of  mankind 
succumb  to  some  kind  of  tuberculosis,  a  slight 
idea  may  be  gained  of  the  importance  of  this 
bacillus,  the  detailed  properties  of  which  cannot 
be  elucidated  in  the  limited  space  of  this  book. 

The  bacillus  tetani  (PL  I.,  Fig.  5)  was  discov- 
ered by  Nicolaier  in  garden  soil  and  in  the  feces 
of  herbivorous  animals,  as  well  as  in  the  pus 
of  individuals  who  had  succumbed  to  tetanus. 
Kitasato  was  the  first  who  isolated  the  bacillus 
in  pure  cultures.     Carle  and  Rattone,  however, 


44  SURGICAL   ASEPSIS. 

previously  discovered  that  tetanus  was  an  in- 
fectious disease.  The  bacillus  stains  with  cold 
aqueous  dyes  and  by  the  method  of  Gram.  It 
is  a  small  rod,  possesses  little  power  of  motion, 
and  forms  spores  of  a  circular  shape.  It  is  an 
obligate  anaerobe,  and  it  is  one  of  the  most  dele- 
terious bacilli.  Before  the  rules  of  antisepsis  or 
asepsis  were  known  and  during  the  period  when 
they  were  poorly  observed  endemics  of  tetanus 
were  repeatedly  experienced.  If  the  tetanus  ba- 
cillus is  implanted  into  the  spine  or  the  sciatic 
nerve  of  a  rabbit,  the  symptoms  of  tetanus  will  be 
observed  within  twenty-four  hours,  and  the  ani- 
mal will  die  in   from  two  to  four  days. 

The  bacilhis  anthracis  (PI.  II.,  Figs.  1-5),  discov- 
ered by  Pollender,  was  first  isolated  by  Koch. 
It  is  an  immovable  rod  to  which  spores,  as  a  rule, 
are  attached  (Fig.  17).  On  gelatin  it  forms  small, 
white,  pin-point  colonies  which  liquefy  their  soil 
slowly.  It  stains  well  with  the  ordinary  dyes  and 
by  the  method  of  Gram.  In  cows  and  horses 
infection  takes  place  from  injections,  while  in  men 
the  bacillus  enters  small  wounds  of  the  skin, 
thereby  causing  the  so-called  "  pustula  maligna." 
Rag-pickers  are  apt  to  acquire  anthrax  pulmo- 
num  by  inhaling  anthrax  spores. 

The  bacillus  of  malignant  oedema  (PI.  III.,  Figs. 
I,  2),  described  by  Pasteur  as  "  vibrion  septique," 
was  discovered  by  Koch.     It  finds  a  nidus  in  the 


SURGICAL    ASEPSIS. 


PivATE   II. 


5  t> 

Micro-organisms. — 1-3.  Anthrax  bacilli:  i,  cover-glass  preparation:  2,  from  the  spleen  of  a 
mouse  ;  3,  from  cultures  on  a  Petri  plate.  4.  Anthrax  bacilli  with  spores,  from  a  gelatin  culture. 
5.  Anthrax  cultures.     6.   Cultures  of  typluis  bacilli. 


SURGICAL    AvSEPSIvS. 


Plate  III. 


\ 


\ 


V 


\ 


5  H 

MiCKO-ORGANisMS. — I.  Eacillus  of  maligiumt  oedema,  from  oedematous  serum.  2.  Cultures  of 
the  bacillus  of  malignant  oedema.  3.  Diphtheria  bacilli,  from  a  diphtheritic  membrane.  4.  Diph- 
theria bacilli,  from  an  agar  culture.  5.  Bacillus  of  mouse-septicsemia,  taken  from  blood.  6.  Cul- 
tures of  mouse-septicaemia. 


INFLUENCE    OF  MICROBES. 


45 


superficial  layers  of  ordinary  garden  soil  and  in 
the  dirt  and  dust  of  carpeted  floors.  It  has  the 
length  of  the  anthrax  bacillus,  and  possesses  con- 
siderable power  of  motion,  which  is  produced  by 
its  flagella.  Colonies  liquefy  gelatin.  As  it  is 
an  obligate  anaerobe,  it  can  be  cultivated  only 
when  the  atmosphere  is  excluded.  Men  as  well 
as  animals  are  susceptible  to  this  bacillus,  which 


Fig.  17. — Strings  of  anthrax  bacilli. 

can  be  stained  with  cold  aqueous  dyes.     It  can  be 
decolorized  by  the  method  of  Gram. 

The  bacillus  dipJitJierice  (PI.  III.,  Figs.  3,  4)  was 
discovered  by  Lofl^er.  Roux,  Escherich,  Brie- 
ger,  and  Fraenkel  produced  true  diphtheria  by 
transferring  cultures  upon  the  opened  trachea  of 
rabbits  and  guinea-pigs.  The  bacillus  diphtheriae 
is  a  straiorht  or  slio^htlv  bent  rod  of  the  size  of 
the  tubercle  bacillus.  It  is  not  movable,  does  not 
contain  spores,  and  does  not  liquefy  gelatin.     It 


46  SURGICAL   ASEPSIS. 

can  be  stained  with  alcoholic  aqueous  dyes  and 
by  Gram's  method. 

Other  microbes,  like  the  bacterium  lactis  aerog- 
enes,  the  bacillus  leprae,  of  rhinoscleroma,  of  mal- 
leus, and  of  typhus,  the  vibrio  cholerse  Asiaticae, 
and  the  spirillum  of  recurrent  fever  and  of  mala- 
ria, are  of  comparatively  little  importance  so  far 
as  concerns  their  direct  interference  with  wounds. 

One  of  the  most  interesting  non-pathogenic 
bacilli  is  the  bacillus  prodigiosus  (PL  I.,  Fig.  6), 
which  is  found  sometimes  on  moist  bread,  pota- 
toes, or  in  milk.  Its  cultures  produce  a  red  color, 
which  has  been  the  foundation  for  the  legends 
of  the  bleeding  bread,  the  bleeding  holy  wa- 
fers, etc. 

A  peculiar  fungus  Is  the  actinomyces  (ray 
fungus,  actinomyces  bovis  s.  hominis;  Figs.  i8, 
19),  discovered  as  early  as  1845  by  B.  von  Lan- 
genbeck  in  a  vertebral  abscess  of  a  man.  It 
used  to  be  classed  among  the  hyphomycetes 
(mould  fungi),  but  is  now  regarded  simply  as  a 
variety  of  schizomycetes.  Its  favorite  domicile 
is  the  maxillae  of  catde,  where  it  causes  indurated 
tumor-like  masses  which  undergo  softening  and 
suppuration.  In  man  the  lower  jaw  (Pig.  19) 
also  is  most  frequendy  the  primary  focus  of  this 
malignant  disease,  which  extends  continuously 
into  the  adjacent  tissue  and  to  internal  organs, 
as  the  lungs,  the  pleurie,  the  heart,  the  liver,  the 


INFLUENCE    OF  MICROBES. 


A7 


kidneys,  the  intestines,  and  the  brain.  The  acti- 
nomyces  can  be  cultivated  on  agar  by  cutting-  off 
oxygen,  in  which  event  yellowish-white  colonies 
are  formed ;  but  if  the  air  has  free  access  an 
ochre-colored  appearance  is  obtained.  Pure  cul- 
tures injected  into  the  cavum  peritonei  of  rabbits 


Fig.  iS. — Actinomyces. 


Fig.  19. — Actinomycosis. 


produce  typical  actinomycosis.  The  fungus 
stains  well  with  the  ordinary  aniline  dyes  and 
by  the  method  of  Gram. 

The  human  body  may  be  invaded  by  these 
micro-organisms  through  solutions  of  continuity 
either  of  the  skin  or  of  the  mucous  membranes 
where  the  microbes  fall  directly  upon  them.  As 
a  rule,  however,  they  are  transferred  or  are  inoc- 
ulated by  other  substances  to  which  they  adhere — 


,48  SURGICAL   ASEPSIS. 

that  Is,  by  the  wounding  instrument,  by  the  fingers, 
by  clothing,  or  by  unclean  wound-dressings.  The 
hair-follicles  and  the  sebaceous  follicles  may  also 
be  factors  in  this  process. 

In  view  of  recent  investigations,  it  seems  more 
and  more  positive  that  the  air  has  no  bearing 
upon  infection,  but  that  contact  is  all-important. 
In  other  words,  the  millions  of  micro-oro-anisms 
suspended  in  the  air  and  which  may  invade  a 
wound  are  usually  innocent  and  of  an  Indifferent 
character.  Were  this  otherwise,  it  would  be  im- 
possible to  perform  laparotomies  and  similar  seri- 
ous operations  in  large  surgical  amphitheatres 
(where  several  hundred  students  are  present) 
with  the  same  success  as  is  clone  in  operating- 
rooms,  where  the  walls,  floors,  and  ceilings  are 
constructed  of  marble,  and  where,  besides  the 
patient,  none  but  the  operator  and  his  assistants 
are  present. 

Lister  originally  thought  that  the  atmospheric 
micro-organisms  causing  decomposition  in  organic 
substances  are  identical  with  those  that  infect 
woynds ;  therefore  he  regarded  the  air  as  the 
most  Important  enemy  to  be  combated.  For  this 
purpose  he  very  naturally  advised  his  spray. 

Nowadays  diametrically  opposite  views  are 
held  ;  that  is,  the  air  is  deemed  the  most  unfavor- 
able place  for  these  micro-organisms,  It  having 
been    proved   that  most   infecting    microbes    of 


SURGICAL    ASEPSIS. 


Plate  IV 


Microscope  with  Abbe's  apparatus. 


INFLUENCE    OF  MICROBES.  49 

wounds  are  destroyed  shortly  after  they  reach  the 
atmosphere.  When  no  solution  of  continuity  of 
the  tissue  is  present,  it  has  been  supposed  that 
probably  the  pyogenic  cocci  enter  through  the 
mucous  membranes  of  the  respiratory  or  the 
digestive  tract,  and  that  migratory  cells  contain- 
ing microbes  invade  the  lymph-  and  blood-circu- 
lation by  migrating  through  the  mucous  mem- 
brane. It  was  further  assumed  that  they  might 
then  establish  themselves  at  any  point  in  the 
system,  and  there  develop  and  multiply. 

At  the  German  Poliklinik  the  writer  observed  a 
typical  cause  of  swollen  and  suppurating  glands, 
which  condition  he  generally  designated  as  "  dirt 
inflammation."  Some  classes  of  immigrants,  com- 
ing from  semi-barbarous  districts,  regard  even  an 
annual  bath  as  an  extravagant  and  foolish  luxury, 
and  carry  all  imaginable  varieties  of  mother  earth, 
especially  on  those  surfaces  of  the  body  not  cov- 
ered by  clothing.  When  they  scratch  themselves 
— for  obvious  reasons — they  become  self-inocu- 
lated with  the  microbes  harbored  in  their  well- 
cultivated  filth.'  As  bacteriological  investieations 
proved,  in  most  of  these  cases  the  staphylococcus 
pyogenes  aureus,  sometimes  the  staphylococcus 
(epidermidis)   albus,  was  found. 

Locally  the  microbes  rapidly  multiply  and  find 

^  "  Surgical  Diseases  of  the  Neck,"  Neio  York  Med.  Journal,  April  29, 
1893. 

4 


50  SURGICAL  ASEPSIS. 

their  way  into  the  connective-tissue  cells  and  the 
walls  of  the  blood-vessels.  Within  twenty-four 
hours  exudation  and  emigration  start  as  direct 
consequences  of  the  so-called  ''phlogosin  "  (Leber) 
caused  by  the  microbes. 

The  white  blood-corpuscles  are  attracted  by 
the  microbes  and  take  them  up  into  their  proto- 
plasm precisely  as  they  might  take  up  pigment, 
transporting  them  into  the  tissues  by  their 
active  locomotion.  The  leucocytes  and  microbes 
accumulate  more  and  more,  while  cellular  infiltra- 
tion and  germ-formation  progress  toward  the 
periphery.  Within  two  or  three  days  softening 
and  breaking  up  of  the  tissues  take  place  in  the 
centre  of  the  focus  of  the  inflammation  ;  in  brief, 
an  abscess  forms. 

There  are  still  some  weak  points  in  the  above 
explanation  of  the  origin  of  pus-accumuladon,  as, 
besides  those  described  above,  there  are  present 
other  micro-organisms  which  may  be  of  some 
importance  in  this  connection.  Buchner,  for 
instance,  in  examining  seventeen  forms  of  bac- 
teria, found  a  substance  that  he  called  "  bacterio- 
proteine,"  which  he  deemed  the  real  cause  of 
suppuration.  This  substance,  he  claims,  is  set 
free  only  when  the  bacteria  are  dead. 

The  question  then  arises  :  Are  the  bacteria  in 
an  abscess  alive  or  dead  ?  In  other  words,  is 
suppuration  caused  by  the  vital  manifestadons  of 


INFLUENCE    OF  MICROBES.    .  $1 

bacteria,  or  by  such  substances  as  form  only 
after  their  death  ?  Every  abscess  contains  nu- 
merous staphylococci  or  streptococci,  either  alive 
or  dead.  But,  besides  these  organisms,  there 
may  be  present  other  forms  of  micro-organisms, 
which  perhaps  remain  unrecognized  because  of 
the  present  defective  means  of  cultivating  them. 

At  any  rate,  it  can  hardly  be  conceived  how 
staphylococci  or  streptococci  alone  can  cause  a 
series  of  very  different  diseases  ;  how  strepto- 
cocci of  endocarditis,  for  instance,  should  be  the 
origin  of  rheumatism,  of  tonsillitis,  of  osteomye- 
litis, of  cerebro-spinal  meningitis,  of  cryptogenetic 
pyaemia,  of  septicaemia,  of  carbuncle,  etc.  Can  it, 
then,  really  be  true  that  an  innocent  tonsillitis  has 
the  same  origin  as  cerebro-spinal  meningitis,  and 
that  only  the  difference  of  the  microbes'  scenes  of 
action  furnishes  the  variation  in  their  significance? 

Reger '  advances  the  theory  that  most  infec- 
tious diseases,  especially  the  so-called  "  pus-dis- 
eases," are  nothing  but  the  local  expression  of 
general  infection  caused  by  a  great  number  of 
different     micro-ororanisms.       Similar    views    are 

o 

expressed  by  Heim.''  The  course  which  infec- 
tious processes  take  is  supposed  to  be  influenced 
by  the  disposition  of  the  patient,  by  the  oppor- 

^  Verhandlungen  der  deutschen  Gesellschafi  fur  Chinirgie,  XXIII.  Con- 
gress, 1894. 

"  Lehrbuch  der  bakieriologischen  Untersiichwig  und  Diagnostik,  Stutt- 
gart, 1894. 


52  SURGICAL   ASEPSIS. 

tunlty  offered  by  his  locus  mifioris  resistentice, 
and  by  the  predilection  of  the  different  mi- 
cro-organisms for  one  place  or  another.  Reger 
distinguished  two  different  typical  groups  of 
infectious  diseases  :  (a)  Specific  contagious  dis- 
eases :  measles,  rubeola,  parotitis,  varicella,  diph- 
theria, scarlet  fever,  influenza,  pneumonia,  ery- 
sipelas, and  conjunctivitis;  (/5)  Pus-diseases :  ca- 
tarrhs and  inflammations  of  the  mucous  mem- 
branes of  the  respiratory  and  digestive  tracts, 
the  anginae,  the  inflammatory  organic  diseases, 
rheumatism,  inflammatory  processes  of  the  skin- 
surface,  and  diseases  which  are  accompanied  by 
suppuration  or  by  the  formation  of  serum,  fibrin, 
or  muco-pus,  and  which  are  dependent  upon 
direct  contact  with  pus  or  dirt,  upon  the  influence 
of  an  external  climatic  noxiousness,  or  upon  a 
certain  diathesis.  In  the  progress  of  these  pus- 
diseases  Reger  found  exactly  the  same  regular 
course  as  in  the  other  group  of  infectious  dis- 
eases. He  therefore  concludes  that  the  usual 
classification  of  all  diseases  has  up  to  the  pres- 
ent been  wrong,  and  that  these  diseases  were 
all  named  either  after  their  most  predominant 
symptom  or  after  the  organ  which  is  most 
involved,  instead  of  being  named  after  their  true 
orio-inators,  the  microbes.  The  whole  classifica- 
tion  customary  through  centuries  could  be  due 
only  to  our  ignorance  of  etiology. 


THE  IMPORTANCE    OF  ASEPSIS.  53 

It  is  thus  seen  that  there  are  still  many  import- 
ant questions  awaiting  elucidation,  which  can  first 
and  foremost  be  given  by  bacteriological  experi- 
ments. Surgery  especially  has  made  such  won- 
derful advances  within  the  past  twenty-five  years 
as  to  justify  great  enthusiasm  for  the  results  of 
the  science  in  the  near  future.  The  main  requi- 
site for  its  further  development  will  be  the  crea- 
tion of  surgico-bacteriological  laboratories.  The 
experience  gained  by  abundant  surgical  material 
will  then  go  hand  in  hand  with  all  the  advances 
of  modern  chemistry  and  bacteriology,  forming  a 
new  and  extremely  useful  combination. 


II.  THE   IMPORTANCE   OF  ASEPSIS. 

Asepsis  is  the  offspring  of  antisepsis.  Both 
methods  tend  to  the  same  end.  At  the  present 
time  it  is  very  difficult  to  draw  a  line  of  demar- 
cation between  them,  much  more  so  as  treat- 
ment cannot  strictly  be  aseptic  without  employing 
means  of  disinfection — that  is,  following  antU 
septic  principles  to  a  certain  extent. 

Antisepsis,  in  the  original  acceptation  of  the 
word,  was  supposed  to  mean  a  method  of  pre- 
venting fermentation  or  putrefaction.  The  result 
obtained  by  observing  its  rules  would  be  asepsis. 
An  aseptic  wound  was  originally  deemed  one 
which  was  so  well  disinfected  by  antiseptics  that 


54  SURGICAL  ASEPSIS. 

no  putrefaction  could  take  place  in  It ;  but  at 
present  the  word  asepsis  is  generally  employed 
in  contradistinction  to  antisepsis.  Instead  of 
striving  to  kill  microbes  brouoht  into  contact 
with  a  wound  by  the  use  of  more  or  less  poison- 
ous chemical  procedures,  the  endeavor  is  now 
to  keep  the  wound  free  from  microbes  without  em- 
ploying so-called  ''germicidal"  chemical  agents. 
Whenever  chemical  substances  can  be  avoided 
during  an  operation,  physical  methods  of  disin- 
fection are  substituted.  Thus  the  aseptic  method 
is  by  its  nature  more  of  a  prophylactic,  as  well  as 
more  of  a  non-poisonous,  character  than  origi- 
nally was  the  antiseptic. 

An  aseptic  wound  is  supposed,  on  the  one 
hand,  to  be  a  wound  which  has  not  first  been 
infected  and  then  freed  from  micro-organisms 
by  disinfection  ;  on  the  other  hand,  it  is  Impos- 
sible to  conceive  among  aseptic  paraphernalia 
articles  that  have  never  been  brought  into  con- 
tact with  micro-organisms,  such  as  instruments, 
operating-tables,  operating-rooms,  etc.  Here  the 
aseptic  designation  signifies  only  that  the  articles 
employed  can  easily  be  rendered  aseptic.  For  in- 
stance, an  instrument  havino-  a  metal  handle  can 
more  readily  be  made  aseptic  than  one  whose 
handle  consists  of  wood  or  of  hard   rubber. 

Recent  investigations  by  Robert  Koch,  E.  von 
Bergmann,     Schimmelbusch,     Schlange,     Riedel, 


THE  IMPORTANCE    OF  ASEPSIS.  55 

Neuber,  Tait,  Koeberle,  Geppert,  Miguel,  Redard, 
Fraenkel,  Nissen,  Schaeffer,  Behring,  Gerloczy, 
New,  Laplace,  and  others  clearly  show  that  the 
so-called  "  orermicidal "  chemical  substances  do 
not  possess  the  disinfecting  power  that  was  long 
attributed  to  them.  This  over-estimation  is  due 
to  the  former  mistake  of  transferring  small  quan- 
tities of  the  antiseptic  fluid  to  the  culture  soil  at 
one  time.  A  piece  of  gauze,  tested  as  to  its  ster- 
ility, will  serve  as  an  illustration.  If  the  gauze 
is  put  on  suitable  soil  and  a  small  quantity  of  an 
antiseptic  fluid  is  transferred  with  it,  the  soil  be- 
comes impaired  and  the  microbes  naturally  fail 
to  multiply. 

Koch  divided  the  object  to  be  disinfected — for 
instance,  infected  silk  thread — into  minute  por- 
tions, while  the  soil  represented  a  considerable 
area,  with  a  view  to  great  dilution  during  culture. 
This  experiment  was  followed  by  surprising  re- 
sults. The  bacillus  of  anthrax  retained  all  its 
vitality  even  after  being  exposed  for  two  weeks 
to  the  influence  of  a  5  per  cent,  solution  of  car- 
bolic acid.  Similar  results  were  obtained  with 
strono;  bichloride  solutions.  Even  the  most 
liberal  irrigation  with  bichloride  of  mercury  did 
not  necessarily  prevent  sepsis.  This  drug,  which 
was  supposed  to  be  the  strongest  antiseptic, 
does  not  destroy  bacteria  with  certainty.  More- 
over, as  all  antiseptics  more  or  less  impair  the 


-56  SURGICAL  ASEPSIS. 

tissues  of  wound-surfaces,  their  resistance  to  the 
microbes  is  weakened. 

But,  despite  all  these  disadvantages,  it  would 
have  been  unjustifiable  to  dispense  with  anti- 
septic solutions  so  long  as  they  were  cred- 
ited with  positive  and  rapid  germicidal  power. 
Thanks  to  very  careful  application  of  such  solu- 
tions in  the  hands  of  great  masters,  these  disad- 
vantages have  been  counterbalanced  by  their 
advantages.  That  Lister  himself  appreciated 
these  disadvantages  is  manifested  by  the  fact 
that  even  at  the  time  of  his  first  publications  he 
advised  a  series  of  precautions  regarding  the 
use  of  carbolic  acid,  which  he  characterized  as  a 
disagreeable  necessity,  especially  because  of  its 
irritating  action  on  the  tissues. 

United  aseptic  wounds  heal  much  more 
quickly  than  wounds  washed  with  antiseptic 
solutions.  In  the  former,  suppuration  and  other 
disturbances  are  observed  only  exceptionally; 
secretion  is  also  much  more  scanty,  thus  render- 
ing drainage  unnecessary.  Poisoning  with  such 
drugs  as  carbolic  acid,  bichloride  of  mercury, 
iodoform,  etc.  need  not  be  feared,  as  they  are  not 
required  in  united  wounds.  Dressings  do  not 
require  such  frequent  changes  as  formerly,  and 
asepsis  is  far  more  economical  than  antisepsis. 

The  advantages  of  asepsis  are  manifest  espe- 
cially  in    operations   on   the    peritoneum,   which 


THE  IMPORTANCE    OF  ASEPSIS.  57 

seems  to  react  more  readily  to  the  application 
of  antiseptic  solutions  than  any  other  organ. 
Therefore  these  strong  and  most  desirable  drugs 
cannot  be  employed  within  the  abdominal  cavity, 
as  the  great  tendency  toward  absorption,  which 
is  another  characteristic  mark  of  the  peritoneal 
membrane,  would  favor  general  poisoning.  If 
infection  by  contact  has  been  prevented  before- 
hand— that  is,  if  all  objects  which  touch  the  peri- 
toneum during  an  operation  are  freed  from  micro- 
organisms— the  abdominal  cavity  may  safely  be 
closed.  No  septic  agent  will  remain  in  the 
cavum  peritonei,  and  all  microbes  that  may  have 
fallen  into  the  cavity  from  the  air  are  innocent 
(compare  the  experiments  of  Petri  and  Cleves- 
Symmer,  p.  147),  and  will  be  kept  in  check  by 
the  living  tissue  itself. 

No  reaction,  as  a  rule,  follows  laparotomies  per- 
formed aseptically,  and  even  inflammatory  pro- 
cesses, which  are  frequently  observed  after  the 
use  of  antiseptic  solutions,  appear  only  under  the 
most  exceptional  circumstances.  The  same  con- 
ditions, especially  absence  of  reaction,  are  verified 
in  carrying  aseptic  principles  over  to  other  healthy 
(non-infected)  tissues. 

Asepsis  proves  to  be  so  far  superior  to  anti- 
sepsis that  the  method  to  be  carried  out  has 
ceased  to  be  a  matter  of  choice.  //  is  simply  the 
duty  of  every  surgeon  to  substitute  asepsis  for  anti- 


58  SURGICAL  ASEPSIS. 

sepsis,  and  to  titilize  the  latter  only  as  a  part  of  the 
astptic  viethod. 

Aseptic  maxims  were  more  or  less  conscien- 
tiously advanced  by  Czerny,  Neuber,  Tait,  and 
others.  Czerny  as  early  as  1877  boiled  his  silk 
ligatures.  The  splendid  results  obtained  by  Neu- 
ber, Tait,  and  others  by  the  observation  of  the 
ordinary  principles  of  cleanliness  are  universally 
known.  But  evidently  ideas  on  the  subject  of 
asepsis  had  occurred  long  before  ;  they  apparently 
date  back  to  before  the  Christian  era,  when  some 
of  the  principles  of  asepsis  were  more  or  less  con- 
sciously carried  out.  Much  of  the  admirable 
knowledge  of  the  great  Hippocratic  era  was  lost 
during  twenty-three  centuries.  Is  it  not  aston- 
ishing that  Hippocrates  laid  great  stress  upon 
frequently  washing  the  patient  with  warm  water 
before  performing  an  operation  ?  Does  not  this 
extraordinary  cleanliness  appear  like  the  dawn  of 
aseptic  principles?  Is  it  not  an  explanation  of 
the  success  of  operations  so  signally  performed  at 
that  period  that  some  are  inclined  to  doubt  the 
authenticity  of  the  records?  It  would  suit  the 
spirit  of  our  sterilizing  age  to  be  reminded  of 
the  frequent  washings  by  the  Jews — a  religious 
rite  ordained  by  Moses,  who  doubtless  was  one  of 
the  greatest  judges  of  human  requirements. 

A  slight  indication  of  what  must  have  been 
lost  of  the  immense  knowledge  of  the  school  of 


THE   IMPORTANCE    OF  ASEPSIS.  59 

Kos,  and  of  how  advanced  Roman  surgery  must 
have  been,  may  be  gained  by  visiting  *'  the  house 
of  the  surgeon"  at  Pompeii.  The  streams  of 
water  constandy  flowing  through  the  streets  of 
Roman  cities  were  certainly  apt  to  remove  mi- 
crobes. Furthermore — and  the  writer  is  not  aware 
that  it  has  ever  been  mentioned  from  this  point 
of  view — the  laree  number  of  small  wells  in  the 
''house  of  the  surgeon"  suggests  at  least  some 
vague  knowledge  of  the  principles  of  asepsis. 

At  a  recent  visit  to  this  most  interesting  place 
the  writer  instinctively  felt  more  than  ever  before 
how  little  advanced  in  many  respects  is  the  pres- 
ent age  when  compared  with  the  medical  civil- 
ization of  many  centuries  ago.  Why  should  not 
the  ancient  surgeon,  with  his  fine  art  of  diagnosis 
and  with  his  powerful  weapon  "  cleanliness,"  have 
obtained  better  results  than  the  suro-eon  of  not 
many  years  ago,  who  went  directly  from  the 
autopsy-room,  after  having  washed  his  hands 
superficially  with  soap  and  water,  to  the  oper- 
ating-room, repeating  his  anatomical  master- 
piece on  the  living  subject,  which  w^as  thus  fre- 
quently made  a  specimen  for  the  autopsy-room? 

The  instruments  excavated  at  Herculaneum 
and  at  Pompeii,  and  now  exhibited  in  the  Vatican 
at  Rome  and  in  the  Museo  Borbonico  at  Naples, 
are  all  of  the  most  admirable  perfection  ;  being 
made  of  steel  or  of  bronze,  they  are  aseptic. 


6o  SURGICAL   ASEPSIS. 

Clear  and  conscientious  aseptic  principles, 
however,  date  only  from  the  time  Robert  Koch's 
genius  created  their  scientific  base  by  testing 
the  value  of  our  disinfecting  means  by  bacteri- 
olocrical  investicrations.  On  this  bacteriological 
foundation  Kuemmell,  Fuerbrinorer,  Von  Bere- 
mann,  Schimmelbusch,  Braatz,  Saenger,  Tripier, 
Kelly,  and  others  were  able  to  elaborate  the  prin- 
ciples of  their  standard  methods. 


III.    MEANS   OF   DISINFECTION. 

It  is  undeniable  that  microbes  have  been 
found  in  wounds  that  have  healed  without  the 
slightest  reaction.  Hence  it  must  be  assumed 
that  infection  does  not  necessarily  depend  upon 
the  invasion  of  a  single  microbe,  but  that  it 
depends  upon  the  quality  or  the  quantity  of 
microbes  present. 

Killing  microbes  is  certainly  the  safest  manner 
of  preventing  their  deleterious  influence  upon 
wounds.  Various  ways  of  accomplishing  this 
extermination  are  known :  some  methods  are 
to  destroy  the  microbes  directly,  to  prevent  their 
development  and  multiplication,  or  to  remove 
them  mechanically.  Nothing  definite  can  yet  be 
said  as  to  the  value  of  other  methods,  such  as 
the  employment  of  so-called  "anti-toxic"  sub- 
stances, or  of  such  medicaments  as,  it  is  alleged, 


MEANS   OF  DISINFECTION.  bl 

deprive  the  micro-organisms  of  their  virulence, 
or  of  procedures  directed  to  rendering  the  sys- 
tem  immune  ao^ainst  the  invasion  of  microbes. 

Sunlight  also  possesses  disinfecting  power. 
Arloing  found  that  anthrax  spores  cultivated  in 
bouillon  died  in  a  few  hours  on  being  exposed 
to  direct  sunlight.  Koch  saw  cultures  of  tuber- 
cle bacilli  die  out  in  from  five  to  seven  days 
by  simply  placing  them  at  a  window.  This 
would  explain  why  simple  laparotomy  is  apt  to 
cure  peritoneal  tuberculosis.  Spllken,  Gottstein, 
and  Krueger  found  that  electricity  is  able  also  to 
destroy  microbes. 

The  most  effective,  and  therefore  the  most  im- 
portant, means  of  disinfection  is  the  mechanical 
method^  which  may  safely  be  said  to  be  at  least 
three-fourths  asepsis.  It  is  accomplished  by  re- 
moving all  dust  and  dirt  by  the  use  of  brushes,  a 
nail-cleaner,  etc.  Manifestly,  if  the  micro-organ- 
isms are  thus  brushed  off,  they  do  not  require 
any  more  disinfection  ;  vice  versa,  dirt  under  the 
finger-nails,  no  matter  how  long  kept  in  a  strong 
antiseptic  solution,  contains  sufficient  micro-or- 
ganisms of  ample  vitality  to  produce  infection 
if  the  mechanical  cleansing  process  is  not  thor- 
oughly carried  out  Therefore  any  question  as 
to  the  greater  and  lesser  virulence  of  such  micro- 
organisms as  can  mechanically  be  removed  Is 
entirely  Irrelevant.     The  value  of  the  so-called 


62  SURGICAL   ASEPSIS. 

"bactericidal"  methods  of  disinfection  depends 
upon  the  proofs  furnished  by  culture-tests  as 
made   by  Koch. 

In  addition  to  the  points  alluded  to  in  Section 
I.,  on  the  "Influence  of  Microbes,"  one  further 
factor  demands  consideration — namely,  the  pres- 
ence of  spores,  whose  vitality  differs  materially 
from  that  of  other  orofanisms.  Oro-anisms  con- 
taining  spores,  such  as  the  anthrax  bacilli,  are 
more  difficult  to  destroy  than  are  those  organisms 
which  do  not  contain  spores.  While  a  2  per  cent. 
solution  of  carbolic  acid  is  apt  to  kill  the  bacillus 
of  anthrax  in  one  minute,  the  spores  of  the  same 
bacillus  are  not  influenced  by  a  5  per  cent,  solu- 
tion of  carbolic  acid,  even  if  they  are  kept  in  it 
for  weeks  ;  therefore  the  bacilli  must  necessarily 
be  well  distinguished  from  the  spores. 

The  following  microbes  contain  no  spores  :  the 
streptococcus  pyogenes,  the  streptococcus  ery- 
sipelatis,  the  staphylococcus  pyogenes  aureus, 
albus,  and  citreus,  and  the  bacilli  of  diphtheria 
and  of  malleus.  The  following  bacilli  contain 
spores  :  the  bacillus  tuberculosis,  anthracis,  and 
tetani.  Tetanus  spores  are  more  easily  destroyed 
than  are  those  of  anthrax  or  of  tuberculosis.  In 
practice  they  may  ordinarily  be  left  out  of  con- 
sideration as  regards  wound-disinfection.  What 
is  needed,  as  a  rule,  is  to  prevent  the  contact  espe- 
cially of  such  cocci   as   the  staphylococcus   pyo- 


MEANS   OF  DISINFECTION.  63 

genes  and  the  streptococcus  pyogenes  or  eryslpe- 
latis  with  wounds,  instruments,  dressings,  etc. 

As  the  development  and  multiplication  of  micro- 
organisms is  predicated  upon  a  favorable  soil  with 
a  certain  temperature  and  quantity  of  moisture, 
their  vitality  very  naturally  can  be  destroyed  by 
depriving  them  of  these  essentials.  This  depri- 
vation can  be  effected  by  chemical  substances  as 
well  as  by  heat,  which  may  be  utilized  as  steam, 
as  hot  air,  and  as  boiling  water.  The  last  men- 
tioned is  the  most  powerful  germicidal  agent  of 
all.  Heat,  by  the  way,  was  employed  by  Hip- 
pocrates and  Oribasius,  who  recommended  using 
the  hot  iron  and  boiling  oil  upon  wounds,  not 
only  to  arrest  hemorrhage,  but,  as  is  maintained, 
also  to  cleanse. 

The  picture  showing  Ambroise  Pare  in  the  act 
of  cauterizing  with  a  hot  iron  the  amputation- 
wound  of  a  soldier's  leg  is  well  known.  Recently, 
M.  G.  Phocas  of  Lille,  Felizet,'  Dreesnau,^  and  M. 
Feannel^  recommended  the  flame  of  a  gas-jet  for 
sterilizing  wounds,  or  the  pouring  of  oil  into  the 
cavities  and  bringing  it  to  the  boiling-point  by  a 
hot  iron,  or  simply  the  touching  of  the  wound- 
surface  with  boiling  water.  The  latter  procedure 
appears   to   be   the  most  rational    among   those 


^  Bulletin  de  la  Chinirgie,  1 892. 

^  Centralblatt  fii)'  Chirurgie,  1893,  No.  3. 

^  Gazette  des  Hopitaux,  Nos.  59  and  62. 


64  SURGICAL   ASEPSIS. 

named,  as  certainly  it  Is  the  least  injurious  to  the 
tissues.  Boiling  water  destroys  all  forms  of  cocci 
in  from  one  to  five  seconds,  and  the  spores  of  the 
bacillus  anthracis  in  two  minutes.  Steam  destroys 
the  spores  in  fifteen  minutes,  while  tubercle  bacilli 
require  twenty  minutes.  A  o.i  per  cent,  solution 
of  bichloride  of  mercury  fails  to  destroy  the 
spores  of  the  bacillus  anthracis  in  twenty-four 
hours ;  chlorine,  iodine,  and  the  cresols  are 
equally  powerless.  A  5  per  cent,  solution  of  car- 
bolic acid,  as  also  the  coal-tar  derivatives,  requires 
much  longer ;  even  chloride  of  calcium  destroys 
the  spores  of  the  anthrax  bacillus  only  after  five 
days',  and  ether  after  thirty  days',  immersion. 

In  view  of  these  statements,  the  exactness  of 
which  can  no  longer  be  doubted,  it  is  surprising 
that  with  2  per  cent,  solutions  of  carbolic  acid 
comparatively  good  results  were,  and  are  still, 
obtained,  and  that  many  surgeons  continue  to 
express  their  great  satisfaction  with,  and  their 
abiding  faith  In,  this  drug,  and  therefore  seek  no 
change.  Yet  it  is  beyond  cavil  that  these  so- 
called  "  satisfactory  "  results  are  due,  not  to  the 
influence  of  a  weak  solution  of  carbolic  acid 
poured  upon  the  instruments  a  few  minutes  before 
operation,  but  to  conscientiously  ioWo^^ \x\g  aseptic 
principles,  the  fundamental  one  of  which  is  the 
thorough  mechanical  cleansing  of  instruments,  the 
surgeon's  hands,  and  the  field  of  operation. 


MEANS   OF  DISINFECTION.  65 

If  an  abscess  has  been  incised,  it  cannot  be 
expected  that  the  knife,  after  having  remained  in 
a  solution  of  carboHc  acid  for  a  few  minutes,  or 
even  for  an  hour  or  more,  becomes  so  well  disin- 
fected that  it  may  safely  be  used  for  a  subsequent 
plastic  operation  or  for  opening  a  similar  abscess. 
Even  if  the  knife  was  cleansed  mechanically  be- 
fore beinor  immersed  in  the  solution,  it  would 
perhaps  require  many  hours  to  render  it 
aseptic.  Manifestly,  no  surgeon  can  wait  so 
long.  But  if  he  simply  dips  the  knife  into  boiling 
water  for  two  minutes,  he  is  absolutely  sure  of 
its  being  perfectly  aseptic.  If,  then,  boilirig  water 
is  so  superior  to  all  chemical  substances,  so  far 
as  concerns  the  certain  as  well  as  the  quick  de- 
stj'uction  of  microbes,  it  should  be  substituted  for 
these  substances  whenever  possible.  The  addi- 
tion of  soda  (i  :  loo)  prevents  the  rusting  of  the 
instruments  and  increases  the  disinfecting  power 
of  boilinor  water.  A  further  orreat  advantage  of 
this  method  of  disinfection  is  its  simplicity  and 
small  expense. 

As  shown  in  Sections  VIII.  and  XVI.,  boiling 
water  in  an  ordinary  kitchen  pot,  and  the  addition 
of  a  tablespoonful  of  soda,  which  may  be  found  in 
the  poorest  tenement-house,  are  all  that  are  re- 
quired for  thorough  disinfection.  In  a  similar  way 
the  dressings  may  be  rendered  aseptic.  The 
difficulty  of  impregnating  gauze,  cotton,  or  other 


66  SURGICAL   ASEPSIS. 

dressing  material  with  chemical  substances,  If 
orlvcerin  or  fatty  or  resinous  inoredients  are  not 
added,  is  well  known.  All  these  constituents 
necessarily  diminish  the  absorbent  power  of  the 
dressinor. 

It  has  always  been  the  general  aim  to  add  so- 
called  "antiseptic"  substances  to  the  gauze,  to 
prevent  decomposition  of  the  discharges  from 
wounds  into  the  orauze.  No  chemical  substance 
has  been  found  that  acts  so  powerfully  in  this 
direction  as  dryness.  Dryness  is  one  of  the 
three  important  enemies  of  bacteria,  as  above 
stated.  Exposing  bacteria  to  dryness  deprives 
them  of  moisture,  one  of  the  conditions  necessary 
for  their  life. 

Only  in  cases  of  very  severe  Infection,  where 
thick  and  putrid  secretion  (ichor)  Is  present,  can 
the  principle  of  drying  not  be  carried  out ;  in 
which  cases  the  surgeon  may  rely  upon  another 
enemy  of  bacteria — anaerobiosis  (see  p.  27). 
Anaerobic  microbes,  as  a  rule,  die  In  pure  oxy- 
gen, while  aerobic  microbes  multiply  in  oxygen, 
but  die  when  deprived  of  it. 

In  wound-cavities  oxygen  Is  absent ;  therefore 
in  such  a  cavity  anaerobic  microbes  find  favorable 
conditions,  while  if  the  cavity  be  exposed  by 
large  incision,  thus  freely  admitting  oxygen,  an- 
aerobic microbes  will  necessarily  be  destroyed. 
These  well-proved  facts  form  the  bacteriological 


MEANS   OF  DISINFECTION.  6'J 

basis  of  the  open-wound  treatmefit,  to  which  the 
surgeon  must  resort  in  cases  of  infection  fp.  176), 
and  which  will  be  discussed  in  Section  XI. 

If  gauze  be  exposed  to  a  jet  of  steam  for  twenty 
minutes,  all  microbes  are  destroyed.  Ordinarily, 
such  gauze  is  superior  to  impregnated  gauze,  on 
account  of  its  much  greater  absorbent  power. 
Furthermore,  it  is  very  questionable  if  all  the 
dressings  containing  bichloride  of  mercury,  car- 
bolic, salicylic,  or  boric  acids,  iodoform,  or  ether 
are  perfectly  aseptic,  as  they  are  made  in  facto- 
ries where  they  must  be  handled  by  many  indi- 
viduals. It  can  scarcely  be  expected  that  these 
working-people  have  full  knowledge  of  their 
great  responsibility. 

The  germicidal  power  of  chemical  substances 
will  often  be  impaired  if  they  form  combinations 
with  the  substances  they  encounter,  which  com- 
binations may  sometimes  account  for  the  unto- 
ward results  of  disinfection.  For  instance,  neither 
faeces  nor  sputa  can  be  disinfected  with  bichloride 
or  other  antiseptic  solutions.  The  disinfecting 
power  of  corrosive  sublimate  upon  pus  and  blood 
is  very  small,  and  when  used  upon  such  albumi- 
noids it  can  be  intensified  only  if  tartaric  acid  be 
added.  An  antiseptic  agent  w^hich  may  be  power- 
ful in  a  watery  fluid  containing  spores  of  the  bacil- 
lus anthracis  may  be  useless  in  alkaline  and  acid 
fluids  or  in  albuminous  mixtures.     Another  ofreat 


68  SURGICAL   ASEPSIS. 

difficulty  in  disinfection  lies  in  the  fact  that  the 
disinfectant  may  not  directly  reach  the  seat  of 
the  microbes. 

There  is  a  orreat  difference  between  disinfect- 
ing  an  instrument  contaminated  by  infectious 
material  and  disinfectinor  a  nest  of  bacteria  im- 
bedded  in  filth  and  similar  substances  or  in 
necrotic  tissue.  Eight  years  ago,  the  writer ' 
emphasized  the  fact  that  the  bacilli  of  diphtheria 
cannot  be  destroyed  as  long  as  they  multiply 
beneath  the  membrane,  from  which  all  antiseptic 
substances  rebound.  A  local  rational  treatment 
can  be  carried  out  only  if  the  antiseptic  sub- 
stances penetrate  the  necrotic  tissue — that  is,  if 
the  membrane  is  removed  first,  so  that  the  mi- 
crobes that  have  settled  in  the  sub-membranous 
tissue  can   directly  be  attacked. 

The  writer  has  several  times,  and  with  appar- 
ent success,  tried  to  remove  the  diphtheritic 
membranes  with  the  sharp  curette,  afterward  ap- 
plying a  bichloride  spray  (i  :  looo)  every  fifteen 
minutes  during  the  first  twenty-four  hours.  In 
performing  tracheotomy  in  a  family  where  four 
children  suffered  from  diphtheria  at  the  same 
time,  the  writer  happened  to  notice  an  extensive 
diphtheritic  membrane  on  the  labia  majora  of  the 
baby.  After  having  curetted  the  membranes  and 
dressed  the  affected  surface,  die  temperature  in 

1  I\Jnv  Yorker  medic inisc he  Presse. 


MEANS   OF  DISINFECTION.  69 

seven  hours  fell  from  104°  to  99°.  The  swelling 
of  the  neighboring  glands  also  subsided  promptly. 
The  effect  was  so  obvious  that  the  same  proced- 
ure was  tried  on  the  tonsils.  The  apparent  cruelty 
of  this  treatment,  the  irritation  of  the  healthy  mu- 
cous membrane,  and  the  difficultyof  employing  the 
treatment  as  soon  as  the  naso-pharyngeal  vault  has 
been  reached  by  the  diphtheritic  process,  naturally 
prevented  its  adoption  in  its  present  shape  by  the 
profession.  The  use  of  the  galvano-cautery,  which 
was  advised  later  on,  experienced  the  same  fate. 
A.  Seibert,  acting  upon  the  same  premises, 
devised  an  ingenious  method  of  penetrating  the 
membranes,  so  as  to  attack  the  microbes  beneath, 
by  using  a  syringe  for  the  sub-membranous  local 
treatment  of  diphtheria.  The  point  of  the  syringe 
consists  in  a  series  of  small  hollow  needles  (like 
those  of  a  hypodermic  syringe),  of  sufficient 
length  to  penetrate  the  membrane,  through  which 
an  antiseptic  fluid  can  be  brought  Into  contact 
wdth  the  sub-membranous  tissues.  The  weak 
point  of  this  method  is  that  the  fluid  comes  into 
contact  with  the  membrane  only  at  that  point  at 
which  the  needle  Is  Inserted,  so  that  merely  a 
limited  area  of  the  tissues  can  be  Impregnated 
with  the  disinfectant.  So  lone  as  surgeons  are 
unfamiliar  with  any  other  than  local  germicidal 
methods,  especially  with  a  method  of  inoculation 
which  will  disinfect  the  system,  a  rational  mode 


JO  SURGICAL   ASEPSIS. 

of  treatment  can  be  reached  only  on  the  basis 
of  the  principles  explained  on  page  68. 

There  is  no  doubt  that  protection  as  well  as  a 
kind  of  disinfection  of  the  body — that  is,  artificial 
immunity  against  a  series  of  infectious  diseases — 
can  be  obtained,  as  shown  in  Section  I.,  in  various 
species  of  animals,  toward  the  influence  of  dif- 
ferent microbes.  Some  animals  do  not  show  any 
reaction  at  all  toward  certain  species  of  microbes 
that  are  highly  virulent  to  other  animals  ;  in  other 
words,  they  are  immune  against  them.  For  in- 
stance, rats  and  dogs  are  immune  against  the 
bacillus  anthracis  ;  men  are  immune  against  the 
cholera  of  chickens,  erysipelas  of  pigs,  etc.  Such 
natural  immunity  is  probably  caused  by  the  dif- 
ferent chemical  composition  of  the  blood.  As  is 
well  known,  infectious  diseases  like  measles,  scar- 
let fever,  and  small-pox  attack  an  individual  only 
once,  because  the  system,  after  having  stood  the 
disease  once,  becomes  immune  against  a  relapse 
of  a  disease  of  the  same  kind.  Such  immunity 
is  called  "acquired,"  in  contradistinction  to  the 
one  called  "artificial,"  which  has  long  been 
known.  Indians  and  Chinese  several  thousand 
years  ago  rendered  themselves  immune  against 
infection  during  epidemics  of  small-pox  by  in- 
oculating themselves  with  the  small-pox  virus. 
They  did  it  by  scratching  the  skin-surface. 
They  produced  a  slight  infection  with  small-pox, 


MEANS   OF  DISINFECTION.  7 1 

which  infection  protected  them  from  acquiring  the 
disease  in  its  greater  or  original  virulence  ;  that 
is,  they  became  artificially  immune  for  a  certain 
leno-th  of  time  ao^ainst  variola.  The  immortal 
merit  of  Jenner  is  that  he  utilized  these  facts 
methodically.  In  accord  with  the  observations 
made  after  vaccinations  with  cow's  lymph  are  the 
numerous  experiments  of  Pasteur,  Koch,  Loeffler, 
Klebs,  Chauveau,  Roux,  Wooldridge,  Kitasato, 
Behring,  Wernicke,  and  others,  who  tried  to  ob- 
tain artificial  immunity  of  the  system  against  cer- 
tain infections  by  inoculations  with  the  weakened 
virus  of  microbes.  There  can  be  no  doubt  that 
mitigated  cultures  of  microbes  are  apt  to  prevent, 
or  at  least  to  diminish,  the  toxic  effects  of  virulent 
microbes  of  the  same  kind  under  certain  condi- 
tions. These  facts  Metschnikoff  tried  to  explain 
by  his  theory  of  the  phagocytes  (compare  Sec- 
tion I.),  founded  on  the  presence  of  substances 
called  "  phagocytes "  which  are  hostile  to  the 
microbes.  The  white  blood-corpuscles  especially 
are  supposed  to  possess  this  peculiarity,  as  they 
are  of  the  same  derivation  as  the  mesoderma,  and 
therefore  have  also  a  decided  digesting  power, 
which  enables  them  to  destroy  microbes  entering 
into  the  circulation.  If  these  elements  are  not 
powerful  enough  to  prevent  the  entrance  of  the 
microbes,  the  latter  multiply  In  the  individual  and 
cause  disease  or  death.    When,  by  means  of  pure 


7-2  SURGICAL   ASEPSIS. 

cultures,  Metschnlkoff  had  inoculated  guinea-pigs 
susceptible  of  infection  with  the  bacillus  anthra- 
cis,  he  found  that  the  phagocytes  would  not 
destroy  the  microbes,  while  in  non-susceptible 
animals  of  the  same  species  destruction  took 
place ;  when  mitigated  cultures  were  used,  the 
phagocytes  showed  enough  power  to  destroy  the 
microbes,  which  had  then  lost  a  great  deal  of 
their  virulence.  By  inoculating  such  animals 
repeatedly  with  mitigated  cultures  Metschnlkoff 
at  last  succeeded  in  makincr  them  resistant  to  the 
most  virulent  cultures. 

That  the  white  blood-corpuscles  really  possess 
the  power  to  destroy  living  microbes  has  been 
doubted ;  it  seems  to  be  more  probable  that  they 
clean  the  tissues  from  dead  organic  particles  by 
enveloping  them. 

Pasteur  and  Klebs  advance  the  theory  that 
after  the  first  inoculation  with  mitigated  cultures 
the  (greater  amount  of  the  substances  which 
represent  the  soil  of  the  microbes  is  consumed 
and  not  reproduced,  so  that  cultures  inoculated 
later  on  do  not  find  an  amount  of  favorable  soil 
sufficient  for  their  development  and  multiplica- 
tion. Similar  hypotheses  were  advanced  by  Chau- 
veau,  Salomon,  Smith,  and  others. 

As  Buchner  claims,  the  albuminous  substances 
of  the  body  exert  bactericidal  power,  and  he 
therefore  advised  the  inoculation  of  susceptible 


MEANS   OF  DISINFECTION.  73 

animals  with  the  blood-serum  of  animals  possess- 
ing natural  immunity.  The  blood-serum  of  ani- 
mals rendered  artificially  Immune  was  finally 
utilized  to  produce  Immunity  in  other  animals. 
Thus,  Behring  and  Kitasato  succeeded  In  pro- 
ducing Immunity  against  tetanus  in  a  manner 
similar  to  that  by  which  vaccination  Immunity  Is 
obtained  against  small-pox.  Recently,  Behring, 
Wernicke,  and  Ehrlich  discovered  that  the  bac- 
tericidal capacities  of  the  serum  of  animals  ren- 
dered Immune  in  the  above-described  manner 
can  be  utilized  for  sanative  purposes.  The  cura- 
tive power  of  the  serum  of  Immunized  animals 
is  supposed  to  depend  upon  its  antitoxic  influence 
upon    the  organism  of  the  affected  individual. 

Good  results  from  this  new  therapy  are  re- 
reported  In  tetanus  and  typhus.  The  splendid 
results  claimed  by  Behring,  Wernicke,  and  Roux 
in  the  treatment  of  diphtheria  are  universally 
known  and  deserve  the  greatest  attention.  The 
effect  and  quality  of  the  serum  depend  upon  the 
degree  of  Immunity  which  the  Immunized  animal 
has  reached,  and  which  can  be  determined  by 
the  frequency  with  which  the  Immune  animal, 
without  belne  killed,  can  be  inoculated  with  the 
minimal  dose  of  the  virus  deadly  for  normal 
animals. 

To  what  extent  the  antao^onism  of  some  mi- 
crobes  can  be  utilized  future  experiments  have 


74  SURGICAL   ASEPSIS. 

yet  to  show.  For  instance,  the  bacilhis  fluores- 
cens  putidus  is  a  decided  antagonist  of  the  pus 
cocci  and  of  the  bacihi  of  pneumonia  and  of  ty- 
phus ;  this  is  evidenced  by  the  fact  that  if  cultures 
of  the  bacillus  fluorescens  putidus  are  produced 
on  gelatin,  they  will  be  non-susceptible  for  the 
implantation  of  the  other  microbes  mentioned. 
Emmerich  was  able  to  save  the  lives  of  rabbits 
poisoned  with  anthrax  bacilli  by  inoculating  them 
with  the  cocci  erysipelatis  or  with  the  bacillus 
prodigiosus  or  pyocyaneus.  Fehleisen,  by  inoc- 
ulating patients  suffering  from  malignant  tumors, 
especially  from  sarcoma,  with  the  streptococcus 
erysipelatis,  has  repeatedly  effected  cures.  The 
results  obtained  by  Bull  and  Coley  corroborate 
the  importance  of  this  discovery. 

If  thus  bacteria  are  destroyers  of  bacteria,  we 
should  not  give  up  hope  of  finding  proper  means 
of  destroying  septic  microbes  by  inoculation  also. 

Injections  with  the  toxines  of  diphtheria  have 
been  tried  by  the  writer  in  a  case  of  septiceemia, 
with  apparent  success.  Toxine  prepared  by  the 
writer  from  the  blood-serum  of  septic  animals 
also  showed  some  effect  in  a  case  of  septicaemia. 

The  discovery  of  practicable  methods  of  carry- 
ing out  the  principles  of  general  disinfection 
would  certainly  be  well  worthy  of  indefatigable 
investigation.  It  should,  however,  not  be  lost 
sight  of    that    the  effects  in  a  test-tube  are  dif- 


MEANS   OF  DISINFECTION.  75 

ferent  from  those  obtained  in  the  Hvinor  orgran- 
ism. 

Another  point  which  renders  disinfection  by 
chemical  substances  impossible  is  the  fact  that 
some  disinfectants  prevent  their  own  penetration 
by  forming  an  impermeable  stratum  around  the 
object  of  disinfection — such,  for  instance,  as  pro- 
duce a  layer  of  coagulated  albumin  around 
balls  of  sputa.  Chemical  disinfectants  contend 
with  similar  difficulties  as  regards  oily  or  fatty 
substances.  Oil  prevents  all  antiseptic  agents, 
even  bichloride,  from  penetrating  tissues.  It  mat- 
ters not  if  the  disinfectants  are  dissolved  or  sus- 
pended in  oil  or  are  dissolved  in  water,  or  if  the 
microbes  are  suspended  in  oil  or  in  fat.  The 
microbes  are  well  protected  by  the  layer  of  fat 
enveloping  them,  and  there  is  no  chemical  sub- 
stance strong  enough  to  destroy  the  microbes  by 
permeating  this  layer. 

Other  experiments  (Schimmelbusch)  have  un- 
dermined confidence  in  the  power  of  chemical 
disinfectants.  There  will  be  mentioned  only  the 
inoculation  (anthrax)  with  septic  substances  of 
the  distal  end  of  a  mouse's  tail.  No  matter  what 
the  kind  and  the  strength  of  the  disinfecting 
agent  used  to  disinfect  immediately  after  inocula- 
tion, mice  so  treated  died  of  sepsis,  except  when 
the  tail  was  amputated  within  at  most  five  min- 
utes after  infection.     Richter  found  the  bacillus 


76  SURGICAL   ASEPSIS. 

anthracis  In  the  lungs,  kidneys,  liver,  and  spleen 
half  an  hour  after  such  an  inoculation. 

It  must,  however,  be  borne  In  mind  that  these 
experiments  do  not,  as  a  rule,  correspond  entirely 
to  the -conditions  found  in  surgical  practice,  be- 
cause they  were  made  with  pure  cultures  of 
highly  virulent  microbes.  As  noted  in  Section 
I.,  on  the  Influence  of  Microbes,  the  difference 
In  the  poisonous  effects  of  the  various  microbes 
consists  In  their  power  of  resistance  against  the 
tissues  of  the  human  body.  Some  of  these  micro- 
organisms multiply  only  In  the  juices  of  the  body; 
others  multiply  only  after  having  destroyed  their 
soil  or  after  having  found  a  point  of  diminished 
resistance — for  instance,  a  solution  of  continuity. 
Despite  the  great  number  of  disappointing 
results  of  such  tests,  carbolic  acid  and  bichloride 
of  mercury  are  still  most  en  vogue  as  disin- 
fectants. 

Carbolic  acid  (phenol),  derived  from  coal-tar, 
has  been  known  since  1834.  No  attention  was 
paid  to  It  until  Joseph  Lister  made  his  revolu- 
tionizing experiments  after  studying  Its  disinfect- 
ing Influence  upon  sewage.  For  years,  notwith- 
standing its  great  disadvantages,  it  occupied  the 
front  rank  as  an  antiseptic  before,  during,  and 
after  all  operative  procedures. 

Koch's  researches  showed  that  weak  solutions 
of  carbolic  acid  are  incapable  of  destroying  such 


MEANS   OF  DISINFECTION.  77 

microbes  as  are  of  importance  to  the  surgeon,  and 
that  even  strono-  solutions  were  uncertain  in  their 
effects  and  required  a  comparatively  long  time  to 
act.  In  full  strength  carbolic  acid  could  not  be 
used  in  those  operations  in  which  it  would  have 
been  most  desirable,  such  as  laparotomy,  etc. 
On  account  of  the  irritating  effects  of  the  drug,  it 
could  not  be  borne  by  so  delicate  a  membrane  as 
the  peritoneum.  Doubtless  hundreds  of  patients, 
especially  children  and  anaemic  and  cachectic  indi- 
viduals, have  succumbed  to  the  poisonous  effects 
of  this  druof. 

Accidents  are  often  due  to  the  careless  use  of 
carbolic  acid  by  the  public  at  large.  Within  the 
past  year  the  writer  was  obliged  to  perform  no 
less  than  seven  amputations  for  gangrene  of  one 
or  more  fingers  caused  by  carbolic  acid.  The 
patients,  generally  suffering  from  a  trifling  injury 
and  knowinof  carbolic  acid  to  be  "  a  orood  wound 

<_>  o 

medicament,"  buy  a  few  cents'  worth  of  the  pure 
drug  at  the  drug-store,  where  purchasers  often 
are  insufficiently  informed  as  to  its  dilution. 
They  add  some  water  to  it  without  mixing  it  well 
by  sdrring,  and  some  of  the  injured  parts  come 
in  contact  with  the  pure  carbolic  acid;  or  they 
mix  it  well,  but  use  too  strong  a  solution.  Con- 
sequently the  tissues,  as  their  fluid  is  taken  out 
from  them,  shrink  as  they  do  in  a  burn  of  the 
third  degree ;  the  circulation  becomes  impeded, 


78  SURGICAL   ASEPSIS. 

and  gangrene  is  the  consequence.  As  local 
anaesthesia  is  caused  by  this  process,  the  patient, 
unfortunately,  feels  relieved,  and  continues  this 
treatment  until  the  gray  or  black  appearance  of 
the  finorer  calls  attention  to  the  oreat  dano;er  to 
which  he  has  exposed  himself.  The  writer  has 
repeatedly  seen  and  heard  of  similar  accidents  in 
gynecological  practice,  where  the  patient,  instead 
of  first  mixing  the  carbolic  acid  in  a  pitcher  or 
a  basin,  put  the  acid  directly  into  her  fountain 
syringe,  added  some  water,  and  stirred  it.  The 
weight  of  the  acid  caused  it  to  settle  into  the 
tube  in  its  pure  state,  while  the  water  in  the  bag 
contained  only  a  trifling  quantity  of  the  acid ; 
hence,  naturally,  when  the  patient  introduced  the 
nozzle  of  the  irrigator  into  the  vagina,  the  drug 
in  its  full  strength  came  in  contact  with  the 
mucous  membrane  and  produced  most  extensive 
and  danorerous  destruction.  The  free  sale  of  this 
drug  should  be  prohibited  by  law.  It  is  evident 
that  Lister  himself  was  well  aware  of  these  dis- 
advantages, for  he  called  carbolic  acid  **  a  neces- 
sary evil,"  which  could  not  be  dispensed  with  so 
long  as  nothing  superior  was  presented. 

Bichloride  of  mercury  (hydrargyrum  bichlora- 
tum  corrosivum,  corrosive  sublimate)  has  been 
known  for  many  centuries.  Its  use  internally 
was  recommended  by  Paracelsus.  After  Robert 
Koch  and  Theodor  Billroth  demonstrated  its  bac- 


MEANS   OF  DISINFECTION.  79 

tericldal  superiority  over  carbolic  acid  it  was  soon 
unanimously  adopted  by  the  profession,  especially 
in  consequence  of  the  efforts  of  Bergmann, 
Schede,  and  others.  Although  it  is  at  least  as 
poisonous  as  carbolic  acid,  no  surgeon  would  now 
care  to  do  without  it.  But  in  connection  with  asep- 
tic wounds  it  should  almost  exclusively  be  used  to 
disinfect  the  field  of  operation  and  the  hands  of 
the  surgeon.  It  cannot  be  employed  for  disinfect- 
inginstruments,  on  accountof  its  destructive  action 
upon  metal.  As  a  solution  it  should  be  used  in 
combination  with  distilled  water  only  ;  if  ordinary 
water  is  used,  the  earthy  substances  (carbonic  alka- 
lies) of  the  water  combine  with  the  mercury,  form- 
ing an  insoluble  combination  (bi-,  tri-,  or  tetra-oxy- 
chloride).  To  prevent  this  the  addition  of  acids 
has  been  suggested.  Fiirbringer  recommended 
salicylic,  acetic,  or  hydrochloric  acid ;  Laplace, 
tartaric  acid  ;  and  Von  Bergmann,  chloride  of  so- 
dium. As  shown  by  Fiirbringer,  the  influence  of 
light  and  air  is  apt  to  impair  the  stability  of  a 
bichloride  solution.  A  convenient  stock  solution, 
preferably  5  per  cent.,  can  be  made  by  dissolving 
equal  parts  of  corrosive  sublimate  and  common 
kitchen  salt  in  hot  distilled  water.  Its  influence 
upon  wounds  covered  with  pus  or  with  blood  is 
insignificant ;  hence,  to  obtain  satisfactory  results, 
the  previous  removal  of  such  substances  is  es- 
sential. 


80  SURGICAL   ASEPSIS. 

Although  the  writer  has  used  bichloride  very 
extensively,  under  proper  precautions,  for  a  num- 
ber of  years,  he  has  seldom  met  with  alarming 
symptoms  attributable  to  the  use  of  mercury  in 
infected  wounds.  Eczema  and  salivation  and  in- 
flammation of  the  gums  were  repeatedly  observed, 
but  these  symptoms  disappeared  promptly  after 
the  druor  was  discontinued.  The  writer  has  re- 
peatedly  employed  a  0.05  per  cent,  solution  to 
wash  off  fibrinous  exudations  of  the  intestine  in 
peritonitis  or  in  gangrenous  herniae,  without  hav- 
ing perceived  any  symptoms  that  could  be  traced 
to  its  use.  It  is  of  the  greatest  importance,  of 
course,  to  protect  the  abdominal  cavity  with  ster- 
ilized compresses,  so  as  to  apply  the  solution 
only  to  that  part  of  the  intestine  lying  outside 
of  the  cavity,  and  immediately  thereafter  to  wash 
it  off  with  sterilized  w^ater. 

Chloride  of  zmc\\2.s  been  recommended  by  Bill- 
roth, Von  Bardeleben,  and  especially  by  Kocher, 
the  last  named  claiminof  that  even  so  weak  a  solu- 
tion  as  2  :  1000  exercises  a  decided  and  all-suffi- 
cient antiseptic  influence.  This  claim,  however, 
has  not  been  corroborated  by  other  surgeons. 
The  value  of  the  chloride  of  zinc  (a  watery  solu- 
tion of  8  per  cent,  being  preferable)  seems  to 
rest  mainly  upon  its  strong  cauterizing  qualities. 
Its  good  effect  upon  torpid  ulcerations,  fistulous 
tracts,  etc.  is  unquestionable.     The  writer  uses 


MEANS   OF  DISINFECTION.  8 1 

it  preferably  on  those  ulcers  for  which  nitrate  of 
silver  is  ordinarily  recommended,  as  the  chloride 
exercises  antiseptic  as  well  as  cauterizing  effects. 
Salicylic  acid  is  made  synthetically  from  car- 
bolic acid,  over  which  it  possesses  the  great  ad- 
vantage of  being  much  less  poisonous.  Only 
when  in  powder  form  and  when  placed  upon 
wounds  in  large  quantities  has  it  really  shown 
poisonous  effects ;  but  this  advantage  is  some- 
what counterbalanced  by  its  weak  antiseptic 
power,  which  can  be  increased  by  the  addition 
of  boric  acid.  The  following  is  a  desirable  for- 
mula for  that  purpose  : 


Salicylic  acid, 

I  part; 

Boric  acid, 

6  parts ; 

Water, 

500  parts. 

Where  large  wound-surfaces  are  involved,  as  In 
the  case  of  burns  or  scalds,  the  writer  found  the 
salicylated  gauze  very  useful   (p.  124). 

Aluminum  aceticum,  consisting  of  sugar  of 
lead  25  parts,  alum  5  parts,  and  water  500  parts, 
is  used  by  Maas  and  Fischer  for  irrigation  and 
as  a  moist  dressing.  It  is  prepared  by  slowly 
addine  the  suear  of  lead  to  the  cold  solution  of 
alum.  It  has  also  been  particularly  recommended 
whenever  there  are  special  reasons  for  appre- 
hending poisonous  effects  from  the  use  of  car- 
bolic acid  or  of  bichloride  of  mercury. 

6 


S2  SURGICAL   ASEPSIS. 

Peroxide  of  hydrogeji  has  recently  been  used 
extensively,  and  apparently  with  good  results. 
Its  precise  value  still  remains  to  be  determined, 
as  the  solutions  generally  used  are  not  absolutely 
germicidal — a  fact  which  can  be  proved  by  the 
experiments  of  Kyle,  who  found  the  tetanus 
bacillus  growing  in  a  15-volume  solution.  Its 
main  advantage  lies  in  its  power  of  destroying 
albuminoid  elements,  upon  which  the  microbes 
multiply.  Unlike  bichloride,  which  is  rendered 
powerless  by  albuminoid  elements,  hydrogen  per- 
oxide is  especially  useful  in  suppurative  pro- 
cesses. 

Pyrozone  (aqua  hydrogenii  dioxidi),  containing 
3  per  cent.  H2O2  in  permanent  solution,  possesses 
the  same  qualities  as  does  the  peroxide,  but  ap- 
parently to  a  somewhat  higher  degree. 

Of  the  vast  series  of  antiseptics  recommended 
during  the  last  decade,  there  may  be  mentioned 
thymol,  natrium,  borax,  naphthalin,  benzoic  acid, 
zincum  sulpho-carbolicum,  terebene,  eucalyptol, 
tinct.  iodi,  china,  chloral,  chloroform-water,  per- 
manganate of  potassium,  camphor,  glycerin,  citric 
acid,  tar-water  impregnated  with  oxygen,  sul- 
phuric acid,  picric  acid,  resorcin,  balsam  of  Peru, 
styrone,  charcoal,  powdered  coffee,  naphtho],asep- 
tol,  salicylresorcin,  ketone,  chromic  acid,  tannic 
acid,  trichloride  of  iodine,  creolin,  pyoktanin, 
lysol,  ichthyol,  thiol,  alumnol,  turmerol,  solveol, 


MEANS   OF  DISINFECTION.  83 

iodol,  salol,  europhen,  aristol,  sulphamlnol,  sozo- 
iodol  (hydrargyrum  sozoiodolicumj,  euphorin,  for- 
malin, and,  last  but  not  least,  iodoform.  Experi- 
ments made  by  the  writer  at  the  New  York  Ger- 
man Poliklinik  with  acetanilide,  phenacetine,  and 
phenocoll  proved  that  these  drugs  also  possess 
antiseptic  qualities.'  The  limits  of  this  volume 
preclude  giving  the  characteristics  of  all  these 
antiseptic  substances.  The  selection  of  any  one 
of  them  seems  frequently  merely  a  matter  of 
choice. 

Iodoform  is  the  ideal  antiseptic  drug ;  despite 
all  that  may  be  said  against  it,  it  must  be  con- 
ceded that  no  equivalent  for  iodoform  has  yet 
been  found.  It  is  easily  dissolved  in  alcohol,  in 
ether,  in  chloroform,  and  in  oils.  According  to 
G.  F.  C.  Mijller,^  iodoform  remains  in  an  unde- 
composed  state  dissolved  in  all  decoctions — w^ith 
glycerin,  in  water  and  watery  fluids,  and  in  mix- 
tures of  the  same  kind  if  they  are  exposed  to  the 
heat  of  a  sterilizing  apparatus.  Naturally,  it 
remains  suspended  also  in  such  mixtures  if  it  is 
exposed  to  the  temperature  of  the  body.  Iodo- 
form incorporated  in  the  system  for  the  most 
part  remains  unchanged ;  this  can  easily  be 
demonstrated  in  the  urine  of  patients. 

*  "  The  Antiseptic  Value  of  Phenocoll  Hydrochlorate,"  N.  V.  Medical 
Jourjial,  March  19,  1893. 
^  Aerztlichcr  Praktiker,  February  22,  1S94. 


84  SURGICAL   ASEPSIS. 

No  drug  has  ever  been  praised  so  highly  and 
condemned  so  fiercely  as  iodoform.  While  hardly 
any  surgeon  was  unconvinced  of  its  antiseptic 
value,  Kronacher,  Fleyn,  Rovsing,  B.  Tilanus,  and 
others  demonstrated  that  streptococci  as  v^ell  as 
staphylococci  can  easily  be  cultivated  in  iodoform 
powder.  This  led  to  the  deduction  that  iodo- 
form has  no  antiseptic  qualities.  But  their  con- 
clusion manifestly  admits  of  modification.  Their 
experiments  demonstrated  only  that  iodoform 
has  no  direct  influence  upon  microbes. 

De  Ruyter  and  Behring  showed  that  iodoform 
renders  products  like  the  ptomaines  (toxines)  of 
certain  microbes  harmless  by  forming  innocuous 
combinations  with  them  ;  furthermore,  a  decom- 
position of  iodoform  by  the  microbes  takes  place, 
during  which  decomposition  a  bactericidal  effect 
is  exerted.  Probably  nascent  iodine  is  set  free 
during  this  process.  The  more  advanced  is  the 
putrefaction,  the  more  intense  is  the  bacterici- 
dal action  of  iodoform ;  hence,  although  it  has 
no  active  disinfecting  power  like  that  of  bichlo- 
ride of  mercury,  it  is  one  of  our  most  valuable 
medicaments,  particularly  as,  besides  its  indirect 
disinfecting  quality,  it  has  the  power  of  reducing 
secretion  and  of  mitigating  pain,  and,  in  addition, 
exerts  a  decided  antitubercular  influence.  (Com- 
pare Section  XL,  on  Open-wound  Treatment,  and 
Section  XIV.,  on  Aseptic  Injection.) 


MEANS   OF  DISINFECTION.  8$ 

The  writer  recently  used  iodoform  for  other 
than  antiseptic  purposes.  Having  frequently 
noticed  the  excellent  influence  of  an  ethereal 
solution  of  iodoform  upon  cysts,  lymphomata, 
goitre,  etc.,  he  used  it  successfully  in  hemor- 
rhoids, varicocele,  hydrocele,  and  varicose  veins.' 
The  splendid  results  obtained  with  the  iodoform 
treatment  after  resection  of  tubercular  joints  and 
after  extirpation  of  tubercular  glands  induced 
the  writer  repeatedly  to  use  comparatively  large 
quantities  of  iodoform  in  tubercular  peritonitis. 
The  striking  manner  in  which  the  powder,  as  also 
the  mixture,  was  borne  by  the  patients  led  to  the 
idea  of  using  it  also  in  general  peritonitis.  The 
injection  of  one  ounce  of  a  lo  per  cent,  mixture 
of  iodoform  and  glycerin  has  repeatedly  been 
made  in  general  peritonitis,  as  also  in  cases  where 
infectious  pus  escaped  into  the  abdominal  cavity 
during  operation.^  The  writer  does  not  claim 
any  specific  results  for  this  treatment,  which 
would  be  useless  in  acute  septic  peritonitis,  but  it 
is  noteworthy  that  of  five  cases  of  suppurative 
peritonitis  so  treated,  in  which  the  chances  of 
recovery  were  very  poor,  four  terminated  favor- 
ably. It  cannot  be  proved,  but  it  is  conceivable, 
that  the  virulence  of  the  pus — that  is,  the  influ- 

^  *'  The  Value  of  an  Ethereal  Solution  of  Iodoform  in  the  treatment  of 
Hemorrhoids,"  N.   V.  Medical  Joia-nal,  July  21,  1894. 

2  "  Tubercular  and  Suppurative  Peritonitis,"  N.  Y.  Medical  Journal, 
April  21,  1894. 


S6  SURGICAL   ASEPSIS. 

ence  of  the  toxines — may  be  weakened  by  the 
co-absorption  of  the  iodoform  (see  p.  255). 

Whenever  abundant  discharges  into  the  ab- 
dominal cavity  may  be  expected,  the  writer  usu- 
ally dusts  the  site  of  operation  with  powdered 
iodoform  ;  ordinarily  it  should  be  used  only  in 
connection  with  gauze,  thus  materially  diminish- 
ing the  danger  of  poisoning.  But,  although  the 
writer  has  used  iodoform  most  extensively  dur- 
ing sixteen  years,  he  never  saw  any  serious 
symptoms  traceable  to  its  employment  that  did 
not  promptly  subside  after  its  discontinuance. 
Some  individuals  have  for  iodoform  a  peculiar 
constitutional  susceptibility,  a  real  iodoform- 
idiosyncrasy,  which  manifests  itself  either  in  the 
appearance  of  papular  or  urticarial  eruptions  on 
the  skin  or  in  symptoms  of  brain-  or  heart-de- 
rangement, the  latter  generally  by  a  frequent, 
small,  irregular  pulse.  Besides  these  symptoms, 
disturbances  of  digestion  and  of  the  nervous  sys- 
tem— headache,  depression,  debility,  and  sleep- 
lessness— may  occur.  Anaemic  or  cachectic 
patients  and  aged  individuals  or  infants,  particu- 
larly if  they  suffer  from  heart  or  kidney  diseases, 
should  carefully  be  watched  when  iodoform  is 
used  on  them,  so  that  the  symptoms  of  intoxica- 
tion may  be  recognized  at  their  earliest  stage 
and  readily  be  overcome.  Undoubtedly,  many 
cases  of  supposed  iodoform-poisoning  were  really 


MEANS   OF  DISINFECTION.  8/ 

septicsemic,  some  of  those  who  reported  such 
cases  not  being  sufficiently  famiUar  with  the  vari- 
able features  of  septicaemia — for  instance,  lacking 
the  knowledge  that  the  low  temperature  was 
sometimes  characteristic  of  its  most  deleterious 
type. 

If  used  in  large  crystals,  the  local  effect  of 
iodoform  is  more  intense  and  endurino-  and 
because  of  its  slow  decomposition  the  drug  is 
less  apt  to  be  absorbed ;  it  displays  its  main 
advantage,  however,  in  the  shape  of  iodoform 
gauze,  the  preparation  of  which  will  be  shown  in 
Section  V.,  and  its  value  and  use  in  Section  XI. 


^ — — ^= ^ 

Fig.  20. — Beck's  bladder-pistol. 


Iodoform  may  be  used  in  connection  with  col- 
lodion as  a  protection  for  wounds  in  which  no 
secretion  is  expected.  Its  value  as  a  suppository 
in  connection  with  cacao-butter  renders  it  useful 
in  fistulous  tracts  and  in  hollow  orcrans  like  the 
rectum  and  bladder.  For  the  easy  introduction 
of  such  suppositories  or  pencils  the  writer  has  de- 
vised his  porte-remede  (bladder-pistol;  Fig.  20).^ 

The    offensive   smell   of    iodoform    cannot    be 

^  "  Ueber   intravesicale    Behandlung,  etc.,"   N'ew    Yorker   medicitiische 
Wochenschriftf  March  3,  1889. 


88  SURGICAL   ASEPSIS. 

neutralized  except  by  impairing  its  value.  Tonka 
and  coffee  beans,  which  were  highly  recom- 
mended as  deodorizers  of  iodoform,  prove  in- 
efficient. If  personal  objection  to  the  odor  of 
iodoform  prohibits  its  use,  aristol  and  the  non- 
poisonous  dermatol  are  the  most  available  sub- 
stitutes. 

It  would  be  of  great  help,  in  determining 
whether  any  or  what  kind  of  disinfection  should 
be  selected,  if  bacteriology  was  sufficiently  ad- 
vanced to  furnish  information,  during  an  opera- 
tion, of  the  character  of  the  infecdng  elements. 
The  sureeon  would  then  know  better  how  to 
combat  them.  In  some  cases,  however — for  in- 
stance, in  suppurative  processes  in  the  abdomi- 
nal cavities,  where  specimens  could  not  be  ob- 
tained before  operation — the  writer  has  tried 
repeatedly  during  operadon  to  get  some  infor- 
mation by  the  microscope  as  to  the  nature  of  the 
microbes.^  Especially  was  a  differendadon  be- 
tween gonococci,  streptococci,  and  staphylococci 
desired.  Bacteriological  investigations — that  is, 
making  cultures — are  of  course  out  of  the  ques- 
tion during  an  operation  ;  furthermore,  the  cha- 
racterisdcs  of  microscopical  slides  of  the  microbes 
in  general  are  not  always  so  distinct  that  a  posi- 
tive differendation  by  the  microscope  alone  could 

'  Comp,  Transactions  of  Ihe  Eleventh  International  Medical  Coni^ress, 
Rome,  March  30,  1894.  "  On  Tubercular  and  Siipimralive  Peritonitis." 


MEANS   OF  DISINFECTION.  89 

always  be  made.  But  In  reference  to  the  most 
frequent  abdominal  operations — that  Is,  to  those 
indicated  by  suppurative  Inflammatory  processes 
of  the  adnexa — valuable  Information  can  be 
gained  by  simple  knowledge  of  the  fact  that,  with 
very  few  exceptions,  either  streptococci,  staphyl- 
ococci, or  gonococci  are  the  originators  of  such 
inflammations.  Other  microbes  need  scarcely  be 
considered,  as  the  bacteriological  investigations 
of  Schauta,  Werthheim,  Menge,  Prochovnick, 
and  others  have  proved.  The  morphological 
features  of  the  three  cocci  mentioned  above,  for- 
tunately, are,  unlike  those  of  many  other  species, 
so  well  marked  that  they  can  almost  always  be 
differentiated  by  a  microscopical  examination 
alone.  For  instance,  the  other  pyogenic  cocci  can 
easily  be  distinguished  from  the  gonococci  bypass- 
ing a  cover-glass  preparation  through  the  flame 
of  an  alcohol  lamp  and  staining  it  by  the  method 
of  Gram;  while  characteristics  of  the  gonococcus 
are  its  peculiar  shape.  Its  size,  and  its  being  found 
within  the  cells.  Another  valuable  point  of  dif- 
ferentiation is  that  as  soon  as  gonococci  are  found 
the  presence  of  streptococci  or  staphylococci  can 
almost  always  be  excluded.  Such  an  exami- 
nation, which,  If  everything  has  been  prepared 
before  operation,  does  not  require  more  than  a 
few  minutes,  would  contribute  to  a  decision  of 
the   question   of   disinfection.      If   the    pus    was 


90  SURGICAL   ASEPSIS. 

found  to  be  either  sterile  or  to  contain  gonococci, 
the  abdomen  could  be  closed  and  union  by  first 
intention  would  be  obtained,  while  if  cocci  of 
greater  virulence,  such  as  streptococci  or  staphyl- 
ococci— in  a  word,  such  cocci  as  are  not  gono- 
cocci— are  found,  disinfection  and  drainage  should 
be  employed.  (Compare  Section  XL,  on  Open- 
wound  Treatment.) 

In  cases  like  pyothorax  or  similar  accumulations 
of  pus,  where  aspiration  of  the  pus  can  easily 
be  done  before  operation,  such  investigation 
can  be  carried  out  by  microscope  and  culture 
mediums.  The  o^reat  value  of  such  bacterioloofi- 
cal  examination  in  diagnosis  and  prognosis  is 
undoubted.  In  pyothorax,  for  instance,  the 
presence  of  streptococci  would  point  to  the 
presence  of  solid  masses,  while  pneumococci  or 
staphylococci  would  indicate  liquid  pus.  But 
such  examinations  do  not  yet  possess  such  a  de- 
gree of  perfection  as  to  be  an  infallible  guide  for 
the  character  of  an  operation  for  pyothorax.^ 

Manifestly,  notwithstanding  the  great  progress 
of  the  last  few  years,  the  methods  of  disinfection 
are  still  far  from  being  perfect,  and  the  main 
dependence  is  in  prophylactic  measures.  Bac- 
terioloo-ical  researches  have  demonstrated  that 
disinfection  is  not  identical  with  the  simple  use 
of  a  so-called  "antiseptic"  agent,  but  that  it  re- 

^  "Pyothorax  and  ils  Treatment,  '  N.  Y.  Medical  Record,  May  19,  1894. 


PROPHYLACTIC  DISINFECTION.  9 1 

quires  a  thorough  knowledge  of  an  entire  series 
of  fixed  principles.  The  mastering  of  disinfection 
does  not  simply  mean  knowing  the  strength  of 
an  antiseptic  fluid,  but  consists  in  knowing  also 
the  condition  of  the  object  to  be  disinfected,  and 
the  vitality  of  the  microbes  established  in  this 
object.  Furthermore,  there  must  be  considered 
all  the  difficulties  of  disinfection  resulting  from 
dirty,  oily,  or  fatty  substances  surrounding  the 
object  to  be  disinfected,  and  those  that  result 
from  chemical  decomposition. 

The  length  of  time  required  to  disinfect  an 
object  is  likewise  of  the  greatest  practical  im- 
portance. There  is  no  advantage  in  knowing 
methods  by  which  a  microbe  can  be  destroyed 
by  keeping  It  in  carbolic  acid  for  three  weeks. 
In  practice  this  knowledge  is  of  no  value,  for  the 
surgeon  cannot  wait ;  he  requires  his  armamen- 
tarium disinfected  within  a  very  few  minutes. 

IV.    PROPHYLACTIC    DISINFECTION. 

The  old  proverb  which  says  that  "  an  ounce 
of  prevention  is  worth  a  pound  of  cure  "  might 
well  serve  as  the  motto  of  asepsis.  Prophylactic 
asepsis — there  Is  no  other  fitting  adjective — rests 
mainly  upon  the  disinfection  of  the  surgeon's 
hands,  of  the  Instruments,  and  of  the  field  of  oper- 
ation.    As  shown  In  Section  I.,  the   number  of 


92  SURGICAL   ASEPSIS. 

micro-organisms  on  the  outer  surface  of  the  body 
is  legion,  while  within  the  tissues  no  microbes 
are  found  ;  therefore  their  removal  from  the  sur- 
face of  the  body  must  be  effected  befo7^e  proceed- 
ing to  any  surgical  operation. 

The  Jiands  and  forearms  of  the  surgeon  are  best 
cleansed  accordinof  to  Fiirbrinorer's  and  Kiimmel's 
methods,  which  depend  more  upon  mechanical 
thoroughness  than  upon  the  choice  of  any  special 
antiseptic.  The  skin  must  be  brushed  energeti- 
cally w^ith  very  warm  water  and  green  soap  for 
three  to  five  minutes,  and  then  be  dried  with  a 
sterilized  towel.  Scrupulous  cleansing  of  the  fin- 
ger-nails with  a  small  metal  nail-cleaner  is  of  the 
greatest  importance.  Not  less  than  one  minute, 
preferably  longer,  should  be  devoted  to  the  nails. 
The  writer  has  used  Braatz's  nail-cleaner  (Fig.  21) 
with  great   satisfaction   for   several  years.     The 


Fig.  21. — Braatz's  nail-cleaner. 

surgeon  should  have  his  nails  cut  short  and 
rounded.  Nail-files  must  be  avoided,  as  they 
form  irregular  surfaces  from  which  the  microbes 
cannot  so  easily  be  removed  as  from  a  sharp 
cut  done  with  scissors.  The  wearing  of  rings 
during  an  operation   shows  a  misconception  of 


PROPHYLACTIC  DISINFECTION.  93 

the  principles  of  asepsis.  Even  if  the  rings  be 
exceptionally  clean,  the  little  folds  of  the  skin  be- 
neath them  can  shelter  micro-ororanisms.  After 
cleanings  the  fingrer-nails  the  skin  must  be  rubbed 
for  about  one  minute  with  a  sterilized-orauze  tam- 
pon  dipped  in  pure  alcohol  (80  per  cent.).  This 
procedure  is  followed  by  washing  and  rubbing  with 
a  bichloride  solution  (i  :  1000)  for  another  minute. 
If  contamination  with  especially  infectious  mate- 
rial shortly  before  the  operation  was  inevitable, 
the  whole  procedure  recited  above  must  be  re- 
peated. The  entire  process  of  disinfection  should 
consume  from  five  to  ten  minutes. 

Howard  A.  Kelly^  recommends  washing  the 
hands  and  the  forearms  with  common  brown 
kitchen  soap  for  ten  minutes,  and  then  covering 
them  with  a  hot  saturated  solution  of  permanga- 
nate of  potash  until  they  are  stained  a  deep  ma- 
hogany-red. After  this  treatment  he  advises 
that  the  hands  be  immersed  and  be  moved  about 
in  a  hot  saturated  solution  of  oxalic  acid  until 
all  the  permanganate  is  removed  ;  they  should 
then  be  dipped  in  milk  of  lime  or  in  plain  water 
to  wash  off  the  oxalic  acid. 

There  can  be  no  doubt  as  to  the  efficacy  of 
both  these  methods,  and  the  choice  is  simply  a 
matter  of  taste.  Disinfection  does  not  depend 
upon  one  or  another  antiseptic,  but  is  an  art/^r 

^  American  Text- Book  of  Gynecology^  Philada.,  1894. 


94  SURGICAL   ASEPSIS. 

se,  and  must  be  learned  as  such.  A  well-trained 
surgeon  will  clean  his  hands  more  effectively  in 
one  minute  by  brushing  than  a  less  experienced 
surgeon  will  do  by  using  the  whole  armamenta- 
riiuji  ascpticiun  for  hours.  It  is  self-evident  that 
after  the  hands  have  been  washed  the  surgeon 
should  not  touch  anything  except  aseptic  articles, 
lest  he  reinfect  himself  before  operation.  If, 
however,  non-aseptic  objects  have  to  be  grasped, 
it  is,  to  save  the  time  for  redisinfection,  sometimes 
advisable  to  put  on  long  sterilized  gloves  consist- 
ing of  linen  or  of  rubber  dam.  With  the  aid  of 
such  aseptic  gloves  all  manipulations  about  the 
patient  that  are  apt  to  be  a  source  of  infection 
can  safely  be  done  without  the  risk  of  contami- 
nation later  on.  As  soon  as  the  necessary  prep- 
arations are  finished,  the  gloves  may  be  taken 
off  and  the  hands  be  washed  only  in  the  bichlo- 
ride solution. 

It  would  be  wrong,  for  instance,  if,  after  having 
brushed  the  hands,  the  cork  of  the  bottle  con- 
taining the  alcohol,  or  later  on  the  vessel  filled 
with  bichloride,  was  grasped  without  having 
gloves  on  or  without  having  those  objects  sur- 
rounded by  sterilized  gauze.  To  avoid  this  con- 
tact entirely  the  alcohol  and  the  bichloride  would 
better  be  kept  ready  for  the  surgeon  separately 
in  basins. 

Braatz,  assuming  that  in  the  cleansing  process 


PROPHYLACTIC  DISINFECTION.  95 

the  water  required  frequently  to  be  changed,  dur- 
ing which  process  the  surgeon  might  be  tempted 
to  turn  the  spigot  on  or  off  with  his  hands,  where- 
by contamination  could  easily  take  place,  devised  a 
pedal  attachment  for  the  spigot,  such  as  is  cus- 
tomary in  many  houses  of  the  better  class  in 
Russia.  A  horizontal  bar  is  substituted  for  the 
handle  of  the  ordinary  hydrant  spigot,  or  the 
stop-cock  of  an  irrigator  is  attached  to  a  chain 
reaching  down  to  near  the  floor,  where  a  lever  is 
attached  to  it.  This  lever  acts  as  a  pedal,  pres- 
sure upon  and  release  of  which  serve  respec- 
tively to  turn  on  and  to  cut  off  the  water-supply. 
There  is  no  doubt  that  such  an  attachment  adds 
greatly  to  the  comfort  of  the  surgeon  In  a  hos- 
pital ;  its  absolute  necessity,  however,  is  open  to 
discussion. 

The  skin  of  the  patient  must  first  of  all  be 
cleansed  by  one  or  several  warm  baths  before 
operation.  When  virulent  contamination  has 
taken  place,  or  If  unclean  individuals  are  handled, 
the  skin,  especially  over  the  site  of  operation, 
should  be  scrubbed  with  ether  after  the  second 
or  third  bath. 

Before  undertaking  operations  upon  parts  such 
as  the  feet,  which,  as  a  rule,  are  not  washed  reg- 
ularly by  most  individuals,  the  thickened  epider- 
mis cannot  be  rendered  sterile  by  following  the 
principles  of    prophylactic    disinfection    for    one 


96  SURGICAL   ASEPSIS. 

time  only.  There  are  legions  of  saprophytes 
and  pathogenic  microbes  sheltered  by  such  skin- 
surfaces,  and  a  mere  temporary  influence  of 
moisture  is  apt  to  cause  them  to  develop  and  to 
multiply.  Such  parts  must  be  prepared  in  the 
most  radical  manner.  For  at  least  three  succes- 
sive days  there  must  be  given  a  bath,  which  is  to 
be  followed  immediately  by  a  thorough  scrubbing 
with  a  bichloride  solution  (1:500).  The  parts 
are  then  surrounded  by  a  compress  of  aluminum 
acetate  covered  with  oil  silk.  This  application 
must  remain  in  situ  until  the  following  day,  when 
the  bathing,  scrubbing,  etc.  must  be  repeated.  If 
these  procedures  are  carried  out  for  three  days, 
the  hypertrophied  epidermis  will  become  macer- 
ated and  may  easily  be   wiped   off. 

It  is  often  advisable  in  preparing  a  patient  for 
an  operation,  such  as  laparotomy,  to  cover  the 
field  of  operation  with  a  poultice  of  green  soap  on 
the  evening  preceding  the  day  of  operation,  after 
prophylactic  disinfection  has  been  carried  out. 
After  the  soap  has  remained  for  three  hours  it  is 
scrubbed  away,  thus  removing  as  much  epithelium 
as  possible.  A  towel  saturated  with  a  bichloride 
solution  is  then  applied,  and  is  allowed  to  remain 
until  shortly  before  the  operation. 

The  field  of  operation  and  its  vicinity  must 
invariably  be  shaved  if  there  is  the  slightest  evi- 
dence of  the  presence  of  hairs  ;  the  region  must 


PROPHYLACTIC  DISINFECTION.  97 

next  be  scrubbed  with  soap  and  hot  water,  and 
afterward  with  alcohol  and  bichloride-of-mercury 
solution. 

All  operations  in  the  vicinity  of  the  umbilicus, 
especially  laparotomy,  require  particular  atten- 
tion to  thorough  disinfection  of  the  part.  This 
disinfection  is  extremely  difficult,  and  is  some- 
times even  impossible.  The  folds  of  the  umbil- 
icus must  be  exposed  as  far  as  possible,  and 
mechanical  cleanliness  must  be  observed  to  the 
utmost  extent.  Whenever  the  exposure  of  the 
folds  of  the  umbilicus  is  difficult,  the  writer  has 
found  it  useful  to  pour  a  teaspoonful  of  a  satu- 
rated solution  of  iodoform-ether  or  of  sterile 
iodoform-collodion  into  its  grooves,  thus  cover- 
inof  and  closino-  the  dangerous  folds. 

Mucous  membranes  cannot  be  disinfected  as 
thoroughly  as  the  skin.  Antiseptic  solutions  are 
not  borne  well,  and  they  even  irritate  the  mucous 
membranes,  the  absorbent  power  of  which  tends 
to  intoxication,  as  clinical  experience  has  repeat- 
edly shown  ;  furthermore,  the  effects  of  bacter- 
icides upon  mucous  surfaces,  if  not  exerted  per- 
manently, are  questionable. 

Steffeck  found  that  irrio^atine  the  vao-ina  with 
a  0.1  per  cent,  solution  of  bichloride  does  not 
exercise  the  slightest  destroying  influence  upon 
the  micro-organisms  of  this  organ  ;  hence  me- 
chanical cleansinor  must  be  resorted  to  as  the  most 

o 

7 


98  SURGICAL  ASEPSIS. 

effective  agent  to  the  desired  end.  If  an  opera- 
tion in  the  vagina  is  to  be  ])erformed,  the  exter- 
nal crenitaha  must  be  cleansed  in  the  manner 
described  on  page  95,  and  the  hairs  must  be 
shaved.  Then  the  vagina  itself  must  be  cleansed 
thoroughly  with  green  soap  and  hot  water.  The 
whole  organ  must  be  wiped  out  energetically 
with  a  piece  of  gauze  dipped  in  green  soap,  and 
afterward  be  wiped  with  gauze  saturated  in  ether. 
Whether  or  not  sterilization  of  the  vaccina  and 
the  uterine  cavity  by  a  steam-atomizer  (like 
that  of  Von  Farkas,  p.  108),  as  recently  recom- 
mended, can  practically  be  carried  out  has  still  to 
be  proved.  The  writer  always  found  it  useful 
to  apply  an  ethereal  solution  of  iodoform  with  a 
spray,  as,  in  case  the  microbes  have  not  thor- 
oughly been  destroyed,  this  solution  will  so  cover 
the  infectious  area  that  the  microbes  will  not 
come  in  direct  contact  with  the  wound  to  be 
made.  The  same  procedures  may  be  undertaken 
in  other  hollow  organs. 

No  one  claims  to  possess  a  safe  means  of 
rendering  strictly  aseptic  the  rectum  or  a  bladder 
containing  stones  bathed  in  purulent  urine ;  yet 
practically  a  great  deal  may  be  done  in  this 
direction.  In  operations  on  the  rectum  it  is  self- 
evident  that  laxatives  should  freely  be  given  and 
enemas  also  be  administered. 

Tampons  consisting  of    sterilized   gauze,   and 


PROPHYLACTIC  DISINFECTION.  99 

connected  with  a  thread  to  make  their  subsequent 
extraction  easy,  should  be  introduced  above  the 
field  of  operation,  to  guard  it  against  contamina- 
tion by  feces  during  the  operation. 

Medicaments,  such  as  calomel,  salol,  etc.,  which 
would  disinfect  the  contents  of  the  intestine  have 
repeatedly  been  recommended,  but  their  efficacy 
remains  still  to  be  proved. 

Thorough  disinfection  of  the  bladder  is  very 
difficult,  and  is  often  impossible.  In  a  healthy 
bladder  containing  healthy  urine  no  microbes 
are  ever  found,  while  in  diseases  of  the  bladder 
they  are  only  exceptionally  absent.  Cazeneuve 
and  Livon  imitated  retention  of  urine  by  con- 
stricting the  pendulous  portion  of  the  urethra; 
after  ligating  the  ureters  they  extirpated  the 
bladder,  extended  by  the  accumulated  urine,  and 
preserved  it  in  an  incubator  for  a  considerable 
length  of  time ;  nevertheless,  decomposition, 
shown  by  the  presence  of  micro-organisms  in 
the  exsected  bladder,  was  observed. 

The  manner  in  which  microbes  enter  the  blad- 
der is  unknown.  It  remains  to  be  proved  that 
they  can  be  brought  from  the  kidneys.  Undoubt- 
edly, in  the  great  majority  of  cases  they  are  car- 
ried into  the  bladder  by  instruments  used  in 
surgical  operations.  Therefore  none  but  per- 
fectly aseptic  catheters,  sounds,  etc.  should  ever 
be  used.    The  special  niodits  operajidi  of  disinfect- 


lOO  SURGICAL    ASEPSIS. 

ing  such  instruments  will  be  shown  in  Section  V., 
in  which  their  steriHzation  is  described.  A  cfreat 
impediment  to  the  fulfilment  of  all  the  premises 
of  asepsis  is  the  ttrethra,  which  must  be  passed 
before  the  bladder  can  be  reached.  As  Manna- 
bero^,  Rovsinor,  and  Lustg^arten  have  shown,  the 
healthy  urethra  always  harbors  whole  series  of 
micro-oro-anisms.  Therefore  it  does  not  suffice 
to  use  sterilized  instruments,  but  the  urethra 
must  also  be  cleansed  before  such  instruments 
are  passed.  This  cleansing  of  the  urethra  is  very 
difficult,  and  uncertain  as  well.  But  it  is  the  duty 
of  the  physician  to  employ  his  best  endeavors, 
and  he  certainly  can  do  a  great  deal  by  observing 
the  followdnof  rules  before  introducincr  a  catheter  : 
(i)  Clean  the  orifice  thoroughly,  after  the  princi- 
ples expressed  on  page  95  ;  (2)  irrigate  the 
urethra  by  the  recurrent  stream  of  an  irrigating 
catheter.  Boric-acid,  Thiersch's  or  bichloride 
(i  :  25,000)  solution,  best  answers  the  latter 
purpose. 

Before  operations  on  the  bladder  or  urethra 
are  undertaken,  irrigations  with  bichloride  (i  :  25- 
000)  should  be  employed  every  ^\^  hours  for 
several  days,  if  possible.  The  urine  may  be  dis- 
infected to  some  extent  by  administering  one  or 
two  drachms  of  salol  within  twenty  four  hours  of 
the  operation.  The  same  preliminary  arrange- 
ments are  required  for  operations  on  the  kidneys. 


PROPHYLACTIC  DISINFECTION.  10 1 

Before  operations  on  the  stomach  are  under- 
taken, repeated  irrigations  of  that  organ  are  re- 
quired. 

Operations  on  the  mouth  require,  first  of  all, 
mechanical  disinfection — that  is,  the  scrubbing  of 
the  teeth,  etc.  with  sterilized  gauze.  It  will  often 
be  necessary  to  use  a  nail-cleaner  to  scrape 
the  teeth,  and  to  brush  them  afterward  with  a 
tooth-pow^der  such  as  the  following :  Pulv.  oss. 
sepiae,  70  parts ;  Pulv.  rad.  iridis  Florent.,  20 
parts;  Bicarb,  sodae,  10  parts.  Then  a  solution 
of  permanganate  of  potassium  or  of  boric  acid 
should  freely  be  applied  as  a  wash.  The  above- 
indicated  procedures  should  be  carried  out,  if 
possible,  during  several  days  ;  that  is,  the  mechan- 
ical disinfection  should  be  repeated  at  least  twice 
a  day,  and  the  washing  of  the  mouth  every  hour. 

The  nose  requires  little  attention,  as  microbes 
are  found  in  it  only  exceptionally.  This  fact  ex- 
plains the  rare  occurrence  of  sepsis  even  after 
the  most  careless  operations  upon  this  organ.  At 
any  rate,  it  should  be  cleaned  repeatedly  before 
operation  with  a  i  per  cent,  boric-acid  solution. 

Thorough  cleansing  of  any  part  of  the  body 
implies  the  need  of  a  good  soap.  In  the  writer's 
opinion,  green  soap  (sapo  viridis)  is  the  very  best 
for  the  purpose.  There  are  some  kinds  of  soap 
in  the  market,  so  made  by  careless  manufacturers 
that  the  animal  fat,  impregnated  with  numberless 


102  SURGICAL   ASEPSIS. 

micro-organisms,  has  not  been  saponified  by  the 
appHcation  of  heat.  Thus,  of  course,  infection 
with  such  a  "  disinfectant"  would  be  possible. 

The  implements  with  which  disinfection  of  the 
body  or  of  any  of  its  parts  is  secured  deserve 
somewhat  detailed  attention  here.  The  most 
important  of  these  implements  is  the  brush,  which 
deserves  much  closer  consideration  than  is  usually 
given  to  it.  Many  surgeons  who  otherwise  may 
be  quite  scrupulous  do  not  hesitate  to  use,  shortly 
before  opening  an  abdomen,  brushes  that  have 
lain  in  the  dirtiest  corner  of  the  room.  Some 
surgeons  who  appreciate  the  great  importance 
of  thorough  cleanliness,  and  who  doubt  that  a 
brush,  after  having  been  used  once  for  removing 
purulent  substances  from  the  surface  of  the  body, 
can  properly  be  sterilized,  advise  their  use  only 
once.  This  limitation  in  the  use  of  brushes 
proving  expensive,  small  bundles  of  sterilized 
compressed  wood-wool  were  devised  as  substi- 
tutes for  brushes.  These  wood-wool  brushes, 
being  cheap,  may  be  thrown  away  after  the  scrub- 
bing. But  it  is  evident  that  for  the  removal  of 
tightly-imbedded  filth  from  small  folds,  grooves, 
and  edges  of  the  body  nothing  can  substitute  a 
brush  in  efficacy ;  certainly  such  material  cannot  be 
dislodged  with  anything  but  a  brush.  Brushes 
— preferably  those  consisting  of  hog-bristles 
mounted  in  a  back  of  wood — should  permanendy 


PROPHYLACTIC  DISINFECTION.  103 

lie  in  a  bichloride  solution.  Should  they  come  in 
contact  with  infectious  material,  they  must  be 
boiled  according  to  the  principles  described  in 
Section  V. 

The  most  indispensable  factor  in  all  the  pro- 
ceedings in  disinfection  is  cleanliness  in  the  ap- 
plication of  the  means  by  which  it  is  attained. 
There  should  be  attached  to  every  wash-stand 
an  enamelled  box  (Fig.  22)  containing  bichloride 


Fig,  22. — Enamelled  brush-box  (Lautenschlager). 

(i  :  1000),  in  which  the  brushes  may  be  placed 
after  beino-  sterilized.  The  solution  must  be 
renewed  at  least  every  twenty-four  hours. 

However,  every  attention  to  appliances,  instru- 
ments, and  dressings  will  prove  futile  if  equally 
strict  care  is  not  taken  by  the  surgeon  of  his 
body,  particularly  the  parts  which  approach  the 
patient.  During  operation  a  basin  with  sterilized 
water  should  always  be  within  reach  of  the  sur- 
geon, so  that  he  may  frequently  cleanse  his  hands. 
A  well-disinfected  brush  should  lie  in  each  basin. 
Basins  containincr  a  solution  of  bichloride  should 


104  SURGICAL   ASEPSIS. 

always  be  ready  in  abundance.  The  bichloride 
in  such  basins  should  be  stained  with  fuchsin,  so 
as  to  make  it  easily  recognizable.  Should  con- 
tamination occur  during  operation,  as  from  the 
bursting  of  an  abscess,  for  instance,  simple  wash- 
insr  in  this  solution  does  not  suffice,  but  the  whole 
disinfecting  procedure,  as  described  in  the  begin- 
ning of  this  section,  must  be  repeated,  not  only 
by  the  surgeon,  but  also  by  his  assistants  and  by 
the  nurses. 


V.    DISINFECTION   OF   INSTRUMENTS    AND 

DRESSINGS. 

The  principle  which  occupies  the  front  rank  in 
Section  IV. — namely,  mechanical  removal  first  of 
all — is  of  equal  importance  as  regards  cleansing 
the  instruments. 

Pus,  blood-coagula,  fat,  and  necrotic  tissues 
adherent  to  instruments  must  be  removed  me- 
chanically by  washing  with  ordinary  water.  It  is 
vi^ell  to  hold  the  instruments  under  the  full  stream 
of  the  hydrant  while  this  v^ashing  is  being  done  ; 
then  they  must  be  put  into  hot  water  to  which 
soda  and  soap  are  liberally  added  ;  in  this  fluid 
the  instruments  must  be  brushed  energetically ; 
then,  after  being  washed  again  under  the  hy- 
drant, they  must  be  rubbed  with  sapolio  or  polish- 
ing powder,  or  some  similar  substance,  and  alco- 


DISINFECTION  OF  INSTRUMENTS  AND  DRESSINGS.  105 

hol.  A  piece  of  leather  should  be  used  for  this 
purpose.  To  be  radical,  washing  in  the  soda- 
solution  may  then  be  repeated,  and  the  instru- 
ments be  dried  thoroughly.  Naturally,  the  instru- 
ments cannot  be  otherwise  than  absolutely  clean 
after  this  procedure  ;  but  they  still  are  far  from 
being  sterile,  as  is  shown  by  Schimmelbusch's 
bacteriological  examinations  of  instruments  clean- 
ed in  this  manner.  After  having  dipped  instru- 
ments thus  cleaned  into  liquid  gelatin  he  could 
always  obtain  cultures  of  microbes. 

As  stated  in  Section  III.,  the  most  powerful 
and  the  promptest  bactericidal  agent  is  boiling 
soda-solution.  Schimmelbusch  proved  that  all 
pyogenic  microbes  die  in  a  i  per  cent,  boiling 
soda-solution  in  two  or  three  seconds.  Even  the 
spores  of  the  most  resistant  microbe,  the  bacil- 
lus anthracis,  are  killed  surely  in  two  minutes. 
This  solution  and  an  enamelled  cookinq-pot  (Fig. 
63)  may  be  obtained  everywhere.  The  size  of 
the  pot  naturally  depends  upon  the  character  of 
the  operation  and  the  amount  of  the  parapher- 
nalia required ;  as  a  rule,  a  pot  about  fifteen 
inches  long,  seven  inches  wide,  and  five  inches 
deep  is  suf^ciently  large.  Very  long  instruments 
are  not  generally  used  by  the  surgeon,  but  only 
by  the  obstetrician,  for  whose  instruments  a  fish- 
boiler  would  be  preferable. 

Before  the  instruments  are  placed  in  the  pot 


I06  SURGICAL   ASEPSIS. 

they  should  be  put  into  compresses  or  Hnen  bags 
held  together  by  satety-pins  or  bound  together 
with  a  string,  the  ends  of  which  can  be  squeezed 
in  between  the  edges  of  the  pot  and  its  cover. 
The  strings  may  serve  as  draw-strings  by  which 
the  suroreon  is  enabled  to  lift  the  bacr  from  the 
sterilizer.  Naturally,  the  bag  must  be  opened 
with  well-disinfected  hands  only.  To  the  boiling 
water  in  the  pot  is  added  pulverized  soda — that 
is,  the  carbonate  of  sodium  (Natrum  carbonicum 
siccum,  P.  G.) — one  tablespoonful  to  the  quart. 


P'iG.  23. — Glass  tray. 

If  this  pure  preparation  cannot  be  obtained,  ordi- 
nary crystallized  soda  must  be  taken,  three  table- 
spoonfuls  to  the  quart.  In  this  solution  the  use- 
fulness (particularly  the  sharpness)  of  knives, 
which  have  to  be  boiled  just  as  well  as  other  in- 
struments, will  not  be  impaired,  especially  if  they 
are  put  into  the  sterilizer  on  a  separate  frame,  so 
as  not  to  be  in  direct  contact  with  the  other 
instruments,  especially  those  which  have  hard 
surfaces.     If  they  are  handled  roughly  and  are 


DISINFECTION  OF  INSTRUMENTS  AND  DRESSINGS.  10/ 

carelessly  put  into  the  basins,  and  if  the  blades 
are  wiped  off  too  forcibly,  the  cutting  instru- 
ments— knives,  scissors,  sharp  spoons,  chisels, 
etc. — are  soon  ruined.  Instruments  having  the 
so-called  "French  locks"  require  particular  care 
around  their  joints.  After  the  water  has  boiled 
for  a  few  minutes  the  pot  is  placed  in  a  basin 
containino-  cold  water  and  there  left  until  it  has 
cooled.  The  instruments  may  then  be  taken 
directly  from  the  pot,  or  they  may  be  enveloped 
in  a  towel  as  described  above,  and  be  taken  from 
the  towel  with  sterilized  forceps  when  required. 
In  hospital  the  writer  prefers  to  put  instruments 
upon  large,  sterilized  dry  compresses  covering 
the  bottom  of  a  thick  tray  of  glass  (Fig.  23), 
agate-ware,  porcelain,  or  hard  rubber,  which  can 
easily  be  disinfected  by  previous  boiling  in  a 
soda-solution. 

It  is  customary  now  to  term  such  disinfection 
sterilization.  As  a  rule,  the  term  "disinfection" 
is  applied  to  infected  organs,  cadavers,  clothing, 
etc.,  while  the  term  "sterilization"  is  applied  to 
surgical  instruments,  culture-media,  and  fluids 
such  as  water,  milk,  etc.  A  sharp  line  of  demar- 
cation, however,  is  with  difficulty  drawn  between 
these  procedures,  both  tending  to  the  same  end. 

Whenever  blood,  fragments  of  tissue,  or  any 
other  substance  adheres  to  an  instrument,  it 
must  be  cleaned  mechanically  in  sterilized  water. 


I08  SURGICAL   ASEPSIS. 

Surgical  instruments  should  consist  only  of 
metal.  Their  disadvantao^es  are  in  beinor  some- 
what  heavier  than  the  old-fashioned  wood-  or 
bone-handled  instruments  and  in  their  tendency 
to  become  slippery  when  wet  with  blood.  The 
difference  in  weight,  however,  and  the  incon- 
venience above  mentioned  are  compensated  for 
by  the  facility  of  sterilization,  which  is  practically 
impossible  with  the   instruments  formerly  used. 


Fig.  24. — Von  Farkas'  steam-atomizer. 

Notches  and  grooves  should  be  avoided,  and 
carved  handles  should  have  places  assigned  them 
in  museums.  The  construction  of  instruments 
should  be  as  simple  as  possible,  and  no  greater 
variety  than  is  absolutely  necessary  should  be 
employed.  Automatic  appliances  should  be 
avoided,  and  it  should  always  be  remembered 
that  the  hands,  and  not  the  instruments,  of  the 


DISINFECTION  OF  INSTRUMENTS  AND  DRESSINGS.  lOQ 

surgeon  perform  the  operation.  Schimmelbusch 
has  shown  that  such  simple  instruments  as  probes 
and  curettes  carry  very  much  fewer  microbes 
than  do  compHcated  instruments  such  as  scissors 
or  forceps,  which  consequently  require  much 
more  disinfection  to  render  them  safe  for  use. 
A  well-trained  surgeon  is  able  to  do  a  great  deal 
of  good  work  with  the  simplest  instruments. 
If  circumstances  compel  the  surgeon  to  operate 
with  wooden-handled  instruments,  his  duty,  at  all 
events,  is  to  boil  them,  and  risk  the  possibility 
of  the  handle  and  the  metal  separating.  If, 
however,  glue  has  not  been  used  in  connecting 
the  metal  part  of  an  instrument  with  its  wooden 
handle,  a  short  boiling  does  not  affect  the  utility 
of  the  instrument. 

Instruments  with  attachments  such  as  ^nirrors, 
electric  lamps,  etc.  cannot  be  kept  sterile,  but 
much  may  be  done  by  careful  mechanical  cleans- 
ing. Their  handles,  however,  can  be  so  sur- 
rounded by  sterilized  gauze  that  contamination 
can  be  avoided.  For  sterilizing  even  so  compli- 
cated an  instrument  as  the  cystoscope  Nitze  has 
recently  devised  an  ingenious  apparatus. 

Rubber  catheters  can  be  made  sterile  by  con- 
necting their  distal  end  with  the  mouth-piece  of 
a  steam-atomizer,  Von  Farkas'  steam-atomizer 
(Fig.  24)  being  the  most  advisable  one. 

Nickel-plated  instruments  are  not  a  necessity 


I  10  SURGICAL   ASEPSIS. 

nowadays,  as  the  addition  of  soda  to  the  boiling 
water  prevents  rusting.  They  are  a  desirable 
luxury,  however,  especially  for  instruments  which 
are  not  in  every-day  use. 

Instrument-cases  should  be  so  made  that  they 
may  easily  be  cleaned.  The  best  manner  of  pre- 
serving instruments  is  to  keep  them  in  cabinets 
composed  of  glass  plates  and  iron.  Tin  is  the 
best  material  for  instrument-cases   (see  Section 

IX.,  p.  155). 

Dressing  material  cannot  be  sterilized  so  easily 

as  instruments.  The  generally  accepted  manner 
of  sterilizing  such  material  is  by  exposure  to 
steam.  The  advantages  of  this  powerful  agent 
have  been  discussed  in  Section  III.  (see  also  p.  1 2 1 ). 
If,  in  private  practice,  a  sterilizer  such  as 
described  below  is  not  at  hand,  a  fish-boiler  may 
be  used  for  the  purpose  of  sterilizing  the  mate- 
rial, or,  if  even  this  cannot  be  obtained,  a  simple 

boiling-pot    whose    cover   fits 
Y^  accurately  may  answer.     If  a 

Mf^^^^J^^        stand  made  of  iron  or  tin  is 
%h^?'*^^^W         inserted  into  the  pot,  it  can  be 
t^'    ^      L       used  for  sterilization  by  steam 
Fig.  25.— Beck's  folding     also.     Such  Stand  should  con- 
improvised  stand.  ^j^^  ^f  ^  perforated  disk  rest- 

ing upon  three  legs  about  three  to  four  inches 
long  (Fig.  25).  This  stand  can  be  lifted  by  the 
holder  reaching  almost  to  the  cover.    The  holder 


DISINFECTION  Of  INSTRUMENTS  AND  DRESSINGS.  I  I  I 


and  the  legs  may  be  folded  together,  and  the 
stand  then  occupies  such  inconsiderable  space 
that  it  can  easily  be  carried  in  a  bag  among  the 
instruments,  etc.  It  is  advisable  to  have  two  or 
three  different  sizes  of  stands  at  hand  for  private 
practice.  The  level  of  the  soda-solution  in 
which  the  instruments  are  boiled  should  be  at 
least  one  inch  below  the  disk,  upon  which  the 
dressing  materials,  the  towels,  sponges,  silk,  etc. 
are  placed.  To  facilitate  free  access  of  steam  to 
the  least  permeable  materials,  such  as  towels,  the 
writer  finds  it  useful  to  place  between  them  per- 
forated tubes.  As  the  instruments  do  not  re- 
quire as  much  time  for  sterilization  as  do  the 
dressing  materials,  they  may 
just  as  well  be  boiled  in  a 
separate  pot  (p.  291). 

While  the  simple  boiling- 
pot  is  as  effective  for  ster- 
ilizing dressing  material  as  a 
more  expensive  apparatus,  it 
does  not,  however  answer  the 
requirements  of  a  hospital  so 
far  as  convenience  is  con- 
cerned. The  simplest  appa-  ^^ 
ratus  of  its  kind  is  the  steril- 
izer of   Koch   (Fig.   26),  but  "^^ 

,  .  -        Fig.   26. — Koch's   sterilizer. 

the    most    approved   one   tor 

such  purposes    is    the    one  devised    by   Lauten- 


112 


SURGICAL  ASEPSIS. 


schlager  (Fig.  27).  It  consists  of  two  copper  cyl- 
inders, one  inserted  into  the  other,  and  both  sur- 
rounded by  a  varnished  hnoleum  cloak.  The  inter- 
space of  about  two  inches  between  the  cylinders  is 
filled  with  water  to  the  rtiiddle  of  the  apparatus, 
the  level  of  the  water  being  shown  by  the  glass 
o-auge  attached  to  the  external  surface  of  the  outer 


Fig.  27.— Lautenschlager's  steam  sterilizer  for  dressings  {A,  exterior  view, 

B,  cross-section). 

cylinder.  The  steam,  after  rising  into  the  small 
space  surrounding  the  interior  copper  cylinder, 
passes  through  the  holes  of  the  upper  part  of  the 
apparatus  and  enters  the  inner  cylinder  intended 
for  the  reception  of  the  dressing  materials.  After 
placing  the  cover  on  the  apparatus,  the  steam 
cannot  escape  upward,  but  passes  through  a  tube 


DISINFECTION  OF  INSTRUMENTS  AND  DRESSINGS.  I  13 

attached  to  the  floor  of  the  sterihzation  space  ; 
thence  it  Is  conducted  through  the  coils  of  a  lead 
pipe  into  a  cooling-vessel  containing  water  for 
condensing  the  steam.  The  cover,  which  fits  her- 
metically,  is  fastened  down  by  strong  screws,  a 
thermometer  being  attached  to  the  centre  of  the 
cover.  When  the  water  is  heated  by  gas  or  by 
alcohol  the  interior  space  containing  the  materials 
to  be  sterilized  is  heated  before  the  steam  enters. 
Thus,  articles  subjected  to  ^' pre-heating  "  [Vor- 
wdrmen,  Schimmelbusch)  are  subsequently  ex- 
posed to  the  steam.  The  time  required  for 
thoroueh  sterilization  of  dressinor  material  in  this 
apparatus  is  forty-five  minutes.  In  hospitals, 
where  steam  can  be  obtained  from  a  boiler,  the 
Lautenschlager  apparatus  is  preferred.  This 
apparatus,  which  has  been  used  in  the  surgical 
wards  of  St.  Mark's  Hospital  for  the  past  three 
years,  has  given  perfect  satisfaction. 

After  the  dressing  materials,  etc.  are  sterilized, 
it  is  of  great  importance  that  they  afterward  be 
kept  so.  The  way  in  which  sterilization  is  gen- 
erally maintained  is  by  keeping  the  materials 
in  bags,  baskets,  cans,  or  boxes.  The  habit  of 
many  surgeons  is  to  pick  the  dressing  from  its 
receptacle  as  required  at  the  time  of  operation, 
and,  placing  it  on  the  table,  to  cut  such  pieces  as 
are  needed.  If  this  practice  is  followed,  control 
of  the  nurses  in  charge  of  this  work  is  absolutely 


114  SURGICAL   ASEPSIS. 

impossible.  No  matter  how  clean  a  table  is,  it 
certainly  is  not  more  sterile  than  an  instrument- 
cabinet,  even  if  the  table  consists  of  nothing  but 
steel  and  iron.  It  is  not  conceivable  that  material 
kept  or  handled  thereon  can  remain  free  from  mi- 
crobes. The  safer  way  to  obtain  sterile  material 
is  to  sterilize  it  in  the  apparatus  jtcst  before  it  is 
7csed.  To  accomplish  this  it  is  best  to  keep  the 
materials  in  a  perforated  tin  box  such  as  devised 


Fig.  28. — Schimmelbusch's  perforated         FiG.   29. — Schimmelbusch's  tio 
tin  box.  box  in  a  portable  leather  case. 

by  Schimmelbusch  (Fig.  28),  and  to  place  the  box 
in  the  steam  apparatus  before  using  the  con- 
tents. The  holes  at  the  top  are  so  arranged  that 
they  can  easily  be  occluded  by  shifting  over  them 
a  movable  strip  of  tin.  After  having  placed  the 
dressing  material,  such  as  gauze  and  sponges  cut 
into  pieces,  rolled  bandages,  etc.  in  the  box  the 
latter  is  put  into  the  steam  apparatus,  the  holes 
being  open.  After  the  box  is  taken  out  the  holes 
are  closed,  thus  rendering  the  box  practically  air- 
tight.    There  the  sterilized  articles  may  remain 


DISINFECTION  OF  INSTRUMENTS  AND  DRESSINGS.  1 1  5 

until  they  are  required  at  the  operation.  In  pri- 
vate practice  such  tin  boxes  may  conveniently  be 
carried  in  a  portable  leather  case  as  devised  by 
Schimmelbusch  (Fig.  29J. 

Whether  heating  the  material  beforehand  is 
really  a  necessity  has,  however,  been  doubted  by 
many  good  authorities.  It  is  true  that  it  prevents 
moistening  of  the  dressings,  but  moist  steam  has 
far  greater  germicidal  potency  than  dry  steam. 
If  some  care  be  taken  in  keeping  the  objects 
to  be  sterilized  away  from  the  interior  walls  of 
the  apparatus,  so  that  they  do  not  come  into 
direct  contact  with  the  water  used  for  conden- 
sation, they  will  not  become  wet;  but  even 
should  this  occur,  it  will  work  no  harm,  being  dis- 
agreeable only.  As  Von  Esmarch  has  shown, 
steam  is  rendered  less  powerful  when  it  is  sur- 
rounded by  gas  produced  by  the.  heating  process. 

Recent  investigations  seem  to  prove  '*  pre- 
heating"  to  be  unnecessary,  so  that  such  compli- 
cated attachments  as  described  above  might  be 
dispensed  with.  It  is  evident  that  the  sterilizing 
process  could  thus  be  rendered  much  more  sim- 
ple and  less  expensive. 

For  the  purpose  of  sterilizing  insh^umejits  in 
hospitals,  Schimmelbusch's  apparatus  (Fig.  30) 
seems  to  be  the  most  desirable.  Great  stress  is 
laid  upon  its  hermetic  occlusion  by  the  cover,  as 
the    temperature    of   water  boiling  in  an    open 


Il6  SURGICAL  ASEPSIS. 

vessel  is  not  equal  in  every  part.  The  hermetic 
occlusion  in  Schimmelbusch's  apparatus  is  ob- 
tained by  a  water-filling,  which  has  also  the 
advantage  of  preventing  rapid  evaporation  of 
the  soda-solution ;  were  this  evaporation  not 
guarded  against,  refilling  would  be  required 
whenever  the  apparatus  was  used  for  any  con- 
siderable leneth  of  time.  The  burners  must 
be  so  arranged   that   the  flame  can  be  kept  as 

high  or  as  low  as  may  be 
desirable.  The  instru- 
ments are  put  into  wire 
a  i_ — ___.!  baskets  (Fig.  30,  b)  pro- 
vided with  wooden  han- 

llitenimulllllir^---l 

Fig.  30. — Schimmelbusch's  gas-heated  apparatus  {a)  for  sterilizing  instru- 
ments ;  b,  wire  basket. 

dies  to  facilitate  their  being  placed  in  and  taken 
out  of  the  apparatus.  After  the  instruments  are 
boiled  in  this  apparatus  for  five  minutes  the  wire 
baskets  may  be  taken  out  and  placed  on  steril- 
ized towels  or  on  vessels  such  as  those  described 
on  page  107.  It  is  optional  with  the  surgeon  to 
keep  the  instruments  in  sterilized  water,  in  a 
solution  containing  alcohol,  or  in  a  solution  of 
soda.     Further  sterilization  is  then  unnecessary. 


DISINFECTION  OF  INSTRUMENTS  AND  DRESSINGS.  1 1/ 

Numerous  other  useful  sterilizing  apparatus 
are  recommended.  The  writer  need  mention 
only  those  devised  by  Korte,  Schiiller,  Rotter, 
Straub,    Mehler,    Kronacher,     Ostwalt,    Arnold, 


Fig.  31. — Braatz  sterilizer  (for  dressings  and  instruments). 

Meyer,  Boeckmann,  and  Braatz  (Fig.  31).  Mally 
of  Paris  '  advises  a  sterilizer  in  which  glycerin 
can  be  boiled  instead  of  water.  Its  advantage 
consists  in  the  possibility  of  boiling  metal,  hard 
rubber,  catgut,  etc.,  as  well  as  knives,  without 
impairing  their  usefulness.  The  apparatus  is 
constructed  similarly  to  Braatz's  dry  sterilizer, 
mentioned  on  page   126. 

For  private  practice   it   is  convenient  to  have 
an  apparatus  which  will  allow  simultaneous  ster- 

^  Zeitschrift  fur  Kranke)ipjiege,  No.  5,  1894. 


ii8 


SURGICAL   ASEPSIS. 


ilization  of  instruments,  dressing  materials,  etc. 
— so-called  "  universal  sterilizers."  In  addition 
to  the  other  requirements,  such  an  apparatus 
must  be  portable. 

For  the  past  three  years  Korte's  portable 
sterilizing  apparatus  (Fig.  32)  has  served  the 
writer  admirably.  It  is  of  such  simple  construc- 
tion that  it  can  be  made   to  order  by  any  tin- 


FlG.  32. — Korte's  sterilizer  for  dressings  and  instruments. 

smith.  This  sterilizer  consists  of  two  compart- 
ments. The  lower  compartment  may  be  used 
separately  as  a  simple  boiling-pot  for  instru- 
ments ;  the  upper  compartment,  being  destined 
for  the  reception  of  the  dressing  materials,  may 
be  attached  to  the  lower  part  by  merely  placing 
it  upon  the  lower  one  after  having  removed  the 
cover  of  the  lower  division.  The  floor  of  the 
upper    compartment    consists    of   wire    netting, 


DISINFECTION  OF  INSTRUMENTS  AND  DRESSINGS.  1 1 9 

which  allows  free  access  of  the  steam  produced 
by  the  boiling  soda-solution.  The  top  of  the 
upper  compartment  is  protected  by  a  cover  so 
arranged  that  by  shifting  it  the  steam  can  escape 
from  time  to  time  as  may  be  desirable,  according 
to  the  amount  of  pressure  produced.  In  the 
upper  compartment  may  be  placed  towels,  dress- 
ings, sponges,  and  silk.  Room  may  also  be 
found  for  two  operating-coats  if  made  of  thin 
material.  This  apparatus,  which  is  heated  by 
alcohol,  the  feeder  being  attached  to  its  side,  can 
easily  be  carried  in  a  canvas  cover. 

The  disadvantage  of  all  these  valuable  appa- 
ratus, however,  is  their  size,  which  makes  it  incon- 
venient to  carry  them  to  operations.  Most  oper- 
ations require  a  sterilizer  of    considerable  size. 


Fig.  33. — Beck's  folding  sterilizer  [a,  apparatus  folded ;  b,  open). 

Small  apparatus,  so-called  ''  pocket  sterilizers," 
permit  only  of  the  sterilization  of  a  few  sponges 
and  the  boiling  of  the  instruments.     To  remedy 


I20  SURGICAL   ASEPSIS. 

this  defect  the  writer  has  devised  a  folding 
apparatus  the  separate  parts  of  which  can  easily 
be  put  together  (Fig.  -^i).  The  lower  division 
(^),  which  is  also  the  smallest  one,  consists  of  a 
reservoir  which  is  half-filled  with  a  solution  of 
soda.  A  wire  net  on  which  the  instruments  are 
placed  fits  into  this  reservoir,  which  fits  into  the 
next  division  (i5),  which  again  fits  into  the  larger 
division  (Cj.  If  desirable,  a  fourth  division  can 
be  set  up.  Wire  sieves  (^)  can  be  inserted 
into  the  projections  of  the  walls  of  division  B 
as  well  as  those  of  C  to  receive  the  dressings, 
towels,  sponges,  etc.  To  the  lower  division  {A) 
are  attached  two  folding  supports,  between  which, 
when  in  use,  is  placed  the  alcohol  lamp  (6^).  The 
lamp  is  so  constructed  as  to  allow  of  its  being 
carried  with  safety  when  filled  with  alcohol. 
Besides  the  regular  attachments — that  is,  the 
alcohol  lamp,  the  wire  sieves  for  the  dressings, 
the  wire  net  for  the  instruments,  two  hooks 
for  pulling  out  the  latter,  and  the  thermometer 
— a  few  instruments,  a  silk-box,  etc.  find  ample 
space  in  division  A.  After  being  folded  together 
the  height  of  the  apparatus  amounts  to  6  centi- 
metres. This  height  is  less  than  one-fourth  of 
that  of  the  whole  apparatus  when  ready  for 
use,  which  amounts  to  27  centimetres.  The 
sterilizer  can  either  be  put  into  an  instrument- 
satchel  or  be  carried  under  the  arm.    Two  quarts 


DISINFECTION  OF  INSTRUMENTS  AND  DRESSINGS.  121 

of  water  after  eight  minutes  will  be  so  heated 
(as  indicated  by  the  thermometer  fitted  into  an 
opening  in  the  lid)  as  to  fill  the  whole  sterilizer 
with  steam  of  a  temperature  of  ioo°  C.  (212°  F.). 
Anthrax  spores  dried  on  silk  ligatures  showed 
no  cultures  after  they  had  been  exposed  to  the 
steam  for  fifteen  minutes. 

As  has  already  been  shown,  the  most  valuable 
material  for  dressings  and  sponges  is  absoi^bent 
gauze,  as  it  possesses  all  the  elements  of  aseptic 
protection.  Being  a  coherent  material,  it  leaves 
none  of  its  fibres  in  the  wound  ;  furthermore,  it 
absorbs  well  and  can  easily  be  rendered  free  from 
pathogenic  microbes.  A  great  many  substitutes 
for  gauze  have  been  advised  ;  of  these  may  be 
mentioned  absorbent  cotton,  wood-w^ool,  turf, 
moss,  savv^dust,  white  or  black  oakum,  and  bran  ; 
also  chopped  straw,  tan-bark,  ashes,  sea-sand,  etc. 

The  best  material  is  not,  as  is  generally  sup- 
posed, the  one  that  immediately  absorbs  the 
ereatest  amount  of  fluid,  but  it  is  that  which  ab- 
sorbs  continually  and  which  is  apt  to  dry  at  the 
same  time.  For  instance,  blotting-paper,  although 
rapidly  absorbing  an  enormous  quantity  of  water, 
is  useless  as  a  dressing  material,  because  its 
power  of  absorption  ceases  as  soon  as  it  is  com- 
pletely saturated  with  the  liquid ;  moreover,  it 
becomes  softened,  contractile,  and  impermeable 
like  pasteboard. 


122 


SURGICAL   ASEPSIS. 


The  absorbing  power  of  absorbent  cotton,  for 
which  a  great  predilection  seems  to  exist,  is  also 
small,  and  it  cannot  be  compared  with  that  of 


ofauze. 


The  most  desirable  dressing  material,  next 
to  gauze,  is  compressed  moss,  whose  absorbent 
powder  is  five  times  as  great  as  that  of  gauze. 
Moss  is  a  very  soft  and  adaptable  material,  and  it 
can  easily  be  sterilized.  It  may  be  used  either 
loose,  after  being  put  into  gauze  bags,  or,  prefer- 
ably, compressed  into  a  tablet-like  shape.  The 
writer  for  the  last  few  years  has  also  exten- 
sively employed   moss-board   as   a  splint.      The 

board,  after  being  dipped  into 
water,  adapts  itself  to  the 
contours  of  the  body  like  a 
plaster-of-Paris  splint,  over 
which  moss-board  possesses 
the  ercat  advantacre  of  beinor 
absorbent  and  much  lighter. 
It  is  indeed  an  ideal  splint 
(Fig.  34),  and  in  its  thick  size 
is  especially  valuable  in  com- 
pound fractures;  for,  should 
the  discharges  exceed  the  absorbent  power  of 
the  gauze  directly  covering  the  wound,  the  moss 
splint  takes  up  the  superfluous  discharge  without 
impairing  the  usefulness  of  the  moss  as  an  immo- 
bilizing factor.     After  operations  in  the  inguinal 


^^:.-5 


Fig.  34. — Moss-board. 


DISINFECTION  OF  INSTRUMENTS  AND  DRESSINGS.  1 23 

region  it  immobilizes  excellently  for  protecting  the 
abdomen  and  thighs,  if  cut  in  the  shape  illustrated 
by  Figure  34.  It  also  dries  constantly  while 
absorbing  at  the  same  time.  It  may  further  be 
remarked  that  the  price  of  moss-board  is  very 
low.  On  further  indications  for  the  use  of  moss- 
board  see  page  195. 

For  protecting  aseptic  wotmds  common  absorb- 
ent gauze,  if  properly  sterilized,  is  sufficient;  for 
the  treatment  of  infected  zvounds,  as  will  be  noted 
in  Section  X.,  gauze  must  be  impregnated  with 
an  antiseptic  substance,  such  as  iodoform,  salicylic 
or  boric  acid,  etc. 

Iodofo7nn  gauze  is  prepared  best  by  dusting  the 
well-pulverized  iodoform  powder  over  the  com- 
mon absorbent  gauze  and  then  rubbing  it  into 
the  meshes,  by  means  of  sterilized  gauze  mops, 
until  the  gauze  has  assumed  a  yellow  color.  It 
is,  of  course,  much  more  convenient  to  prepare 
iodoform  gauze  by  simply  dipping  it  into  an 
emulsion  of  glycerin  or  into  an  ethereal  solu- 
tion of  iodoform  ;  but  the  addition  of  glycerin 
seriously  impairs  the  power  of  absorption,  and 
gauze  impregnated  with  an  ethereal  solution  de- 
composes easily. 

Iodoform  gauze  may,  after  being  rolled  up  in 
a  piece  of  gauze,  be  sterilized  in  steam.  Ster- 
ilization should,  however,  not  be  kept  up  longer 
than    is    absolutely    required,    as    decomposition 


124  SURGICAL    ASEPSIS. 

may  be  caused  by  it.  The  gauze  may  be  pre- 
served in  sterilized  jars,  but  it  is  preferable  not 
to  keep  a  large  stock,  but  to  prepare  it  anew  as 
required.  A  strength  of  lo  per  cent,  is  gener- 
ally sufficient.  It  should  be  borne  in  mind  that 
the  higher  the  percentage  of  the  iodoform,  the 
weaker  becomes  the  absorbing  power  of  the 
o^auze. 

The  indications  for  the  use  of  iodoform  eauze 
will  be  described  fully  in  Section  X.,  on  Treat- 
ment of  Infected  Wounds,  and  in  Section  XL, 
on  Open-wound  Treatment. 

Gauze  can  be  impregnated  with  almost  any 
antiseptic  drug.  Besides  iodoform  gauze  the 
writer  uses  only  salicylated  or  dei^matol  gauze ^  and 
this  only  when  a  substitute  for  iodoform  gauze  is 
required — as,  for  instance,  in  the  event  of  the 
occurrence  of  eczema,  which  may  sometimes  be 
produced  by  the  use  of  iodoform  (see  pp.  86,  227). 

Salicylated  and  dermatol  gauze  is  made  up 
reliably  by  most  druggists. 

Bandages  should  be  kept  in  stock  In  large 
quantities.  They  can  easily  be  sterilized  in  steam. 
Various  lengths  and  widths  are  required,  and 
they  should  consist  either  of  common  absorbent 
gauze,  of  starched  gauze,  or  of  Canton  flannel. 


STERILIZATION  OF  CATGUT,   SILK,   ETC.         1 25 

VI.  STERILIZATION   OF   CATGUT,  SILK,  ETC. 

With  the  advent  of  the  aseptic  era  the  desire 
for  absorbable  sutures  and  Hgatures  was  natu- 
rally more  strongly  developed  than  ever  before. 
Rhazes  in  1813,  and  later  Hennen,  Young,  Law- 
rence, Astley  Cooper,  and  Dupuytren,  had  sutures 
made  of  an  organic  material  consisting  of  leather 
or  of  gut,  but  their  experiments  did  not  prove 
very  encouraging.  Joseph  Lister  established  the 
repute  of  gut  by  claiming  that  after  its  disinfec- 
tion in  carbolic  acid  it  admirably  serves  its  pur- 
pose without  being  a  source  of  infection. 

There  can  be  no  doubt  that  catQ^ut  is  one  of 
the  most  desirable  materials  in  surgery,  and  noth- 
ing has  yet  taken  its  place.  It  would  indeed  be 
"the  ideal  suture"  but  for  the  objection  presented 
by  the  great  difficulty  it  offers  to  sterilization. 
More  than  one  hundred  methods  have  been 
advised,  but  the  great  number  offered  is  always 
the  best  proof  of  the  weakness  of  each.  Raw 
"  catgut,"  as  ordinarily  obtained  commercially,  is 
infected  with  the  microbes  of  its  source — namely, 
the  submucous  coat  of  a  sheep's  intestine ;  fur- 
thermore, it  contains  much  fat.  The  latter  may 
easily  be  removed  by  soaking  the  gut  for  forty- 
eight  hours  in  ether,  but  it  still  remains  to  be 
proven  whether  the   microbes  in  cateut  can  be 

o 

destroyed  with  absolute  certainty. 


126 


SURGICAL   ASEPSIS. 


Of  the  many  sterilizing  methods  advised  and 
most  extensively  used,  there  may  be  mentioned 
the  following:  After  the  fat  has  been  removed 
by  immersion  in  ether  the  gut  is  soaked  in  an 
alcoholic  bichloride  solution  (i  :  lOo)  for  forty- 
eio-ht    hours   and   is   then   preserved  in   alcohol. 


Fig.  35. — Braatz's  metal  box  for  sterilizing  and  keeping  catgut  sterile. 

Another  method,  which  is  deserving  of  more  con- 
fidence, is  to  boil  the  catgut  in  alcohol.  This  is 
done  by  putting  the  catgut  in  a  strong  glass  bottle 
containing  alcohol.  After  the  tightly-closed  bottle 
has  been  kept  in  boiling  w^ater  for  fifteen  minutes 
the  catgut  is  assumed  to  be  sterile,  according  to 
bacterioloofical  examinations  on  artificial  soil  made 
of  catgut  so  treated.  The  chance  of  the  catgut 
being  well  sterilized  is  increased  by  repeating  the 
boiling  process  on  several  days  in  succession. 
Braatz^  devised  an  apparatus  (Fig.  35)  which, 

'  Die  Grundlagen  der  Aseptik. 


STERILIZATION  OF  CATGUT,   SILK,   ETC. 


127 


he  claims,  renders  catgut  absolutely  sterile,  useful, 
and  durable.  After  having  extracted  the  fat  from 
the  gut  with  ether,  he  winds  it  on  metal  rolls. 
These  rolls  are  placed  in  the  metal  box,  whose 
cover  is  hermetically  closed,  so  that  no  dust  can 
enter.  The  amount  of  catgut  needed  only  at  one 
time  is  drawn  throug-h  a  small  hole  in  the  side  of 
the  box  and  is  cut  off;  thus  the  catgut  remain- 
ing in  the   box   continues   uncontaminated,  and 


Fig.  36. — Braatz's  apparatus  for  sterilizing  catgut. 

therefore  sterile.  When  it  is  proposed  to  sterilize 
catgut  the  metal  box  containing  it  is  put  into  the 
dry  sterilizer  (Fig.  36).  The  catgut  can  also  be 
preserved  in  the  same  box  in  which  it  has  been 
sterilized.      The    principle    of   the  operation  of 


128 


SURGICAL   ASEPSIS. 


Braatz's  apparatus  consists  in  the  fact  that  one 
wall  of  a  flat  metal  box  filled  with  liquid  paraffin 
lifts  and  lets  fall  a  cone  with  the  fall  and  rise  of 
the  temperature  in  the  apparatus.  The  supply 
of  gas  is  thus  automatically  regulated,  keeping  a 
uniform  temperature,  which  is  supposed  to  be  an 
important  point  in  dry  sterilization. 

A  much  favored  way  of  preserving  catgut  in 
alcohol  is  to  keep  it  in  glass  jars  having  hard- 
rubber  caps  (Fig.  2)7)'  The  writer,  however,  pre- 
fers to  use  the  metal  box 
(Fig.  42),  devised  by  himself, 
which  is  a  modification  of 
Braatz's  and  which  can  also 
be  used  for  silk  (seep.  136). 
But  even  when  cultures 
could  not  be  obtained  from 
catgut  prepared  in  the  above 
manner,  suppuration  result- 
ed from  its  use,  as  reported 
by  Kocher  and  Klemm. 
Klemm  used  catgut  steril- 
ized in  bichloride  and  alco- 
hol, and  kept  it  in  alcohol 
for  several  weeks.  With  sterilized  scissors 
he  cut  several  small  pieces  of  this  gut  and 
placed  them  on  different  soils — namely,  on  pep- 
tonized gelatin,  agar-agar,  and  bouillon.  The 
soils  thus  inoculated  were  observed  in  ordinary 


Fig.   37. — Glass  jars   for 
catgut. 


STERILIZATION  OF  CATGUT,   SILK,  ETC.         1 29 

temperature  as  well  as  in  an  incubator  kept  at 
a  constant  temperature  of  98°  F.  No  cultures 
appearing  in  three  weeks  in  the  test-tubes  nor  on 
the  Petri  plates,  the  catgut  was  deemed  sterile; 
it  was  then  used  in  operations  such  as  ampu- 
tations, herniotomies,  etc.  Notwithstanding  the 
strictest  aseptic  precautions,  it  was  repeatedly 
found  that  locally  as  well  as  generally  everything 
appeared  normal  during  the  subsequent  five  or 
six  days,  but  between  the  seventh  and  tenth  days 
there  occurred  a  slight  elevation  of  temperature. 
The  vicinity  of  the  wound  became  swollen  and 
red,  and  upon  separating  its  edges  there  was 
revealed  the  presence  of  a  deep-seated  abscess. 
It  was  clearly  evident  that  suppuration  had  taken 
place  around  the  catgut  sutures ;  while  in  the 
skin,  where  silk  was  used,  no  suppuration  was 
discovered.  It  was  then  deemed  possible  that 
infection  had  originated  from  the  centre  of  the 
catgut  suture.  As  absorption  of  the  catgut  be- 
gins at  its  periphery,  it  might  be  assumed  that 
microbes  locked  in  the  centre  of  the  gut  were  set 
free  when  absorption  reached  that  part  of  the 
suture.  This  would  be  in  harmony  with  the  fact 
that  signs  of  suppuration  generally  appeared  a 
week  after  the  insertion  of  the  sutures.  To  as- 
certain the  correctness  of  this  assumption  slices 
of  catgut  prepared  in  the  manner  previously 
described  were  pulled  into  small  pieces  by  steril- 
9 


130-  SURGICAL   ASEPSIS. 

ized  pins  and  put  on  the  same  soil,  but  the  result 
was  negative. 

The  following  experiments  were  also  made  by 
Klemm  at  the  surgical  clinic  in  Dorpat,  where, 
so  long  as  silk  was  exclusively  used,  suppuration 
was  only  exceptionally  observed : 

A  number  of  cats,  toward  whom  the  same 
strict  aseptic  precautions  were  observed  as  is 
done  in  operations  upon  human  beings,  were 
treated  by  making  in  both  thighs  long  incisions 
reaching  down  to  the  muscular  tissue.  A  me- 
dium sized  sterile  catgut  suture  was  implanted 
in  the  wound  of  one  thigh,  while  a  silk  suture 
was  buried  in  the  other:  four  days  later  the 
animal  became  weak,  refused  nourishment,  and 
died  a  few  hours  after  the  first  symptoms  of 
infection  appeared.  Where  the  catgut  was  im- 
planted nothing  abnormal  was  observed  on  the 
superficies,  but  after  opening  the  united  edges  of 
the  wound  there  escaped  a  brownish  liquid  of  an 
offensive  odor.  The  cellular  tissue  was  also  dis- 
colored and  cedematous. 

After  having  exposed  the  muscular  layer  into 
which  the  catgut  was  implanted,  and  which 
showed  the  same  change,  the  catgut  was  found 
sodden,  of  an  offensive  odor,  and  of  a  reddish- 
brown  color.  The  silk  implanted  into  the  other 
thigh  presented  nothing  abnormal.  The  frag- 
ments of  catgut,   as   well   as    those   of  the   silk, 


STERILIZATION  OF  CATGUT,   SILK,   ETC.         I3I 

were  removed  with  sterilized  instruments  and 
put  into  separate  Petri  plates  filled  with  gelatin. 
Two  days  later  the  plate  containing  the  catgut 
fragments  showed  a  rich  colony  of  pathogenic 
microbes,  while  the  one  with  the  silk  proved 
sterile.  These  experiments  caused  Klemm  to 
maintain  that,  while  catgut  may  be  sterile,  it  is  a 
favorable  soil  for  the  establishment  of  micro- 
organisms. It  is  an  organic  membrane,  and 
under  the  influence  of  moisture  and  warmth  it 
is  very  prone  to  decomposition  should  it  come 
into  the  slightest  contact  with  micro  oro-anisms. 
As  the  normal  tissues  of  the  body  shelter  no 
micro-organisms,  the  theory  was  advanced  that 
they  reached  the  catgut  through  the  air,  and 
that  in  connection  with  this  material  the  pos- 
sibility of  infection  from  the  atmosphere  was 
greater  than  was  attributed  to  this  source.  At 
any  rate,  the  action  of  chemical  reagents  in 
test-tubes  may  be  prompt,  while  their  action 
is  questionable  upon  micro-organisms  within  a 
wound.  A  wound  has  no  dead  soil,  as  has  a 
test-tube  contai7iing  gelatin.  Furthermore,  test- 
tube  experiments  must  needs  differ  from  the 
conditions  found  in  a  wound,  where  the  mi- 
cro-organisms encounter  living  tissues.  It  is 
still  an  open  question  whether  Klemm's  and 
Kocher's  experiments  demonstrate  the  propriety 
of  discarding  a  material  that  offers  such  decided 


132  SURGICAL  ASEPSIS. 

advantages  as  does  catgut.  It  is  possible  that  the 
catgut  of  these  experimenters  was  infected,  de- 
spite all  the  precautions  reported,  and  that  greater 
care,  as  well  as  sterilization  by  heat,  would  per- 
haps have  rendered  it  just  as  safe  as  silk. 

Be  it  as  it  may,  the  above  experiments  show  that 
sterilization  of  catgut  requires  such  great  care 
as  to  prevent  a  considerable  number  of  surgeons 
from  using  it  altogether,  or  at  least  intraperi- 
toneally.  The  great  fear  of  imperfect  steriliza- 
tion— a  fear  strengthened  by  reports  which 
traced  suppuration  and  even  death  to  the  use 
of  catgut — induced  the  writer  to  forego  the  use 
of  this  material,  to  his  great  regret,  in  operations 
where  concealed  sutures  are  used — that  is,  just 
where  catgut  displays  its  most  desirable  quality. 
If  after  an  abdominal  section  the  abdomen  be 
closed,  the  site  of  an  infection  caused  bv  a  cato-ut 
ligature  cannot  be  discovered  at  a  period  early 
enough  to  allow  of  effective  disinfection  ;  while  if 
used  on  the  skin  surface  only,  the  symptoms  of 
infection  from  catgut  are  so  early  perceived  that 
by  such  procedures  as  immediate  removal  of  the 
infectious  material,  opening  of  the  wound,  etc. 
general  infection  may  be  prevented.  In  opera- 
tions on  the  surface,  however,  the  only  advantage 
possessed  by  catgut  over  silk  consists  in  the  fact 
that  removal  of  the  sutures  is  unnecessary  after 
they  have  served  their  purpose.     If,  as  may  con- 


STERILIZATION  OF  CATGUT,    SILK,  ETC. 


133 


fidently  be  expected,  an  absolutely  reliable  meth- 
od of  sterilization  is  invented,  catgut  will  repre- 
sent the  most  perfect  ligature  material. 

Silk  can  very  easily  be  sterilized  by  winding  it 
on  glass  spools  and  boiling  it  in 
a  soda-solution  for  at  least  five 
minutes.  Silk  is  used  in  various 
sizes,  according  to  the  vessels 
or  pedicles  to  be  tied.  As  it  can 
be  boiled  with  the  instruments 
just  before  it  is  required,  the 
question  of  its  preservation  in 
a  sterile  condition  is  unim- 
portant.      In    hospitals,    botdeS        Fig.  sS-Ligatme-bot- 

with  ground-glass  stoppers  and  tie  with  ground-glass  stop- 
spools  on  glass  racks  (Fig.  38)    ^f^'  "''^,  °"'  '^°°^  °" 

^  ^  \      &    vj    /      glass  rack. 

are    frequently  used    to    pre- 


P"iG.  39. — Aseptic  case  for  silk  sutures. 

serve  sterilized  silk.  Some  surgeons  prefer  to 
keep  it  in  test-tubes  stoppered  with  rubber  corks 
w^hich  may  be  carried  in  an  aseptic  suture-case 


134  SURGICAL  ASEPSIS. 

(Fig.  39).  Others  prefer  to  keep  silk  on  reels 
of  polished  plate  glass  (Fig.  40)  which  can  be 
carried  in  sterilized  paper  or  linen  or  in  small 
metal  boxes. 

Schimmelbusch^   recommends    sterilization   of 
silk  in  steam.     The  silk  threads  are  wound  on 
rolls    attached    to   a    metal    box 
(Fig.  41),  which  is  put  for  three- 
^^    quarters  of  an  hour  in  the  ster- 
ilizer, where  it  can  be  sterilized 
Fig.  4o.-Reeis  of    with    the     dressings,    etc.     Silk 
polished    plate    glass    remains  sterile  and  dry  in  these 

with     three    cuts    for     ,  ^r^i         r  i  •       •         i 

various  sizes  of  silk.  ^oxes.  The  fact  that  It  IS  dry 
materially  facilitates  threading  it 
into  needles  and  tying. 

The  writer  has  devised  a  metal  box  which,  by 
combining  the  advantages  of  Schimmelbusch's 
apparatus  for  silk  and  that  of  Braatz  for  cat- 
gut, can  be  used  for  sterilizing  and  preserving 
catgut  as  well  as  silk  (Fig.  42). 

Silk  is  certainly  the  safer  material,  and  It  is 
far  preferable  for  ligating  large  blood-vessels,  in 
which  operation  too  early  absorption  of  a  catgut 
ligature  might  prove  fatal.  Although  silk  Is  not 
absorbed  in  the  majority  of  cases,  if  strict  asepsis 
has  been  observed  It  will  be  encysted,  and  thus 
practically  fulfil  the  same  requirements  as  though 
it  were  absorbed.     It,  furthermore,  has  the  advan- 

'  Aseptische  Wundbehandlung. 


STERILIZATION  OF  CATGUT,   SILK,   ETC.         1 35 

tage  that  even  thin  silk  may  be  used  for  the 
ligation  of  large  blood-vessels.  The  impossibil- 
ity of  using  catgut  in  delicate  plastic  operations, 
in  which  only  the  thinnest  kind  of  silk  is  advis- 
able, makes  the  latter  exceptionally  useful  for 
this  special  purpose. 


Fig.  41. — Scliimmelbusch's  metal  boxes  for  sterilizing  silk  and  keeping  it 
sterile  {^a,  box  closed  ;  b,  box  open). 

Recently,  simple  thread  has  been  recommended 
as  a  substitute  for  silk,  on  account  of  its  lower 
price  and  because  it  can  be  sterilized  as  thor- 
oughly as  silk.  But  silk  can  be  handled  better 
and  can  more  easily  be  tied. 


136 


SURGICAL   ASEPSIS. 


Si/kwo?'7n  gilt,  which  is  furnished  in  bundles 
like  the  reels  used  by  anglers,  can  very  easily  be 
sterilized.  Some  suroeons  favor  silkworm-orut 
because   of  its   smooth  surface  and  its   density, 


Fig.  42. — Beck's  metal  box  for  sterilizing  and  preserving 
catgut  and  silk, 

deeming  it  on  this  account  the  least  irritating  of 
sutures. 

Silver  wire  may  quickly  be  sterilized  in  boiling 
water.  It  is  not  at  present  so  extensively  used 
as  formerly,  when  silk  was  not  so  easy  of  steril- 
ization. The  writer  still  finds  it  very  useful  for 
sewing  bone-fragments  and  for  "buried  sutures" 
in  operating  for  ventral  hernia.  It  may  also  be 
used  in  plastic  operations  as  a  relaxation-suture 
or  as  a  propliylactic  suture  (see  p.  166). 


DRAINAGE   AND   IRRIGATION.  1 3/ 

The  use  of  parchment  sutures,  of  threads  made 
of  the  aorta  of  the  ox,  or  conslsthig  of  horse- 
hair, kangaroo-tendon,  etc.,  is  merely  a  matter 
of  choice. 


VIL    SPONGES,    DRAINAGE-TUBES,    AND 
IRRIGATION    FLUID. 

Sponges. — There  can  be  no  doubt,  from  a 
strictly  technical  standpoint,  that  ordinary  marine 
sponges,  such  as  are  generally  used,  are  the 
best  material  for  the  purpose  of  sponging,  being 
elastic  and  possessing  immense  absorbent  power. 
Their  sterilization,  however,  is  very  difficult,  if  not 
uncertain.  The  safest  method  of  sterilizinor 
sponges  would  be  by  boiling  in  a  soda-solution 
for  ten  minutes;  but  as  this  procedure  materially 
reduces  their  elasticity,  and  as  shrinkage  hardens 
them,  their  usefulness  is  much  impaired  by  such 
sterilization.  Schimmelbusch  therefore  advises 
the  following  method :  Sponges,  as  ordinarily 
purchased  commercially,  are  freed  from  dirt  by 
beating  out  the  sand  and  shells  in  their  alveoli. 
They  are  then  soaked  for  several  days  in  cold 
water  slightly  acidulated  with  muriatic  acid,  and 
arc  kneaded  from  time  to  time.  They  are  then 
washed  thoroughly,  first  in  cold  and  then  in  warm^ 
water,  until  the  water  remains  clear.  They  are 
then   enveloped   in  a  linen   sheet  and   put    into 


138  SURGICAL   ASEPSIS. 

a  boiling  i  per  cent,  soda-solution.  To  limit 
shrinkage  while  boiling,  it  is  advisable  to  take 
the  boiling  solution  from  the  fire  shortly  before 
the  sponges  are  immersed.  After  remaining  in 
this  hot  solution  for  thirty  minutes  they  are 
squeezed  out  and  freed  from  the  soda  by  again 
immersing  and  squeezing  them  in  boiled  water. 
They  may  then  be  kept  in  a  ^  per  cent,  bichlo- 
ride solution. 

Regarding  the  uncertainty  of  sterilization,  care- 
ful surgeons  do  not  care  to  use  marine  sponges 
after  they  have  come  in  contact  with  infectious 
material.  But  to  discard  sponges  after  having 
employed  them  only  once  is  extravagant,  con- 
sidering their  price  ;  it  is  quite  natural,  therefore, 
that  most  surgeons  have  given  up  ordinary 
sponges,  and  in  their  stead  use  only  small  steril- 
ized gauze  mops,  which  admirably  answer  all  the 
purposes  of  sponges. 

As  tampons  in  hemorrhages  and  for  opera- 
tions on  the  mouth  and  the  pharynx,  marine 
sponges  are  of  considerable  value,  especially 
when  fastened  to  a  sponge-holder.  The  writer 
during  the  past  few  years  has  been  satisfied  to 
operate  without  using  a  single  marine  sponge 
during  operation,  as  the  fear  of  insufficient  ster- 
ilization outweiofhed  all  other  considerations. 

Gauze  used  for  ordinary  surgical  dressings 
may  be  sterilized  according  to  the  methods  de- 


DRAINAGE  AND  IRRIGATION.  1 39 

scribed  in  the  previous  section.  If  kept  in  the 
steam  of  a  steriHzer  for  thirty  minutes,  the  most 
resistant  spores  in  it  will  be  killed.  Mops  may 
be  made  of  a  number  of  folds  of  gauze  loosely 
hemmed  at  the  edges.  They  should  be  so  cut 
as  to  preclude  the  risk  of  leaving  loose  threads 
in  the  wound.  For  the  abdominal  cavity  gauze 
pads  from  six  to  ten  inches  square  are  useful. 
The  orreatest  advantag^e  of  this  material  is  that 
after  being  used  it  may  be  thrown  away,  its  cost 
beincr  insio^nificant.  Small  bao-s  filled  with  moss 
or  with  wool  may  serve  just  as  well,  and  they 
are  somewhat  cheaper.  A  supply  of  such  mops 
may  always  be  kept  in  a  glass  jar,  but  it  is 
preferable  to  sterilize  them  shortly  before  they 
are  used. 

Drainage-tubes  seem  to  be  almost  as  near  the 
stage  of  surgical  extinction  as  are  sponges. 
Nothing  characterizes  the  lukewarm  aseptic  sur- 
geon more  than  his  predilection  for  drainage, 
which,  in  fact,  means  nothing  less  than  that  he 
lacks  confidence  in  his  own  system  of  asepsis. 
If,  on  the  one  hand,  no  antiseptic  irritants  have 
been  used  during  operation,  if  all  aseptic  pre- 
cautions have  been  observed,  and  if  no  wound- 
pockets  have  been  left,  discharge  from  the 
wound  is  practically  nil,  consequently  such  a 
case  will  not  give  rise  to  anything  that  needs 
to  be  carried  off  by  a  tube.     On  the  other  hand, 


140  SURGICAL   ASEPSIS. 

if  operations  in  infected  or  suppurating  areas 
are  to  be  performed,  drainage  will  be  a  necessity, 
but  even  then  it  should  not  be  effected  by  rubber 
drainage  as  a  rule,  but  by  gauze  packing,  as 
shown  in  Section  XL,  on  Open-wound  Treat- 
ment (pp.  190  and  218).  Still,  surgeons  cannot 
entirely  do  without  drainage-tubes  where  neither 
union  by  first  intention  is  to  be  expected  nor 
thorough  packing  with  gauze  is  to  be  performed. 
The  most  desirable  tubes,  then,  are  those  made 
of  soft  India-rubber.  They  must  be  as  wide  as 
possible,  and  they  should  be  fixed  at  the  most 
dependent  part  of  the  wound.  They  may  be 
fastened  in  the  wound  either  by  sewing  them  to 
the  skin  or  by  transfixing  one  end  of  the  tube 
with  one  or  two  safety-pins.  It  is  perhaps  need- 
less to  say  that  the  pins  must  be  boiled  in  a  soda- 
solution  before  use.  Holes  should  be  made  in 
the  sides  of  the  tube  at  short  intervals,  and  the 
tube  should  be  cut  off  nearly  flush  with  the  skin. 
Rubber  drainage-tubes  can  easily  be  sterilized 
by  placing  them  for  five  minutes  in  boiling  soda- 
solution.  This  length  of  time  suffices  for  the 
destruction  of  all  microbes.  If  the  rubber  be  kept 
in  the  solution  much  longer  than  five  minutes, 
its  usefulness  will  be  impaired.  In  steam,  rub- 
ber drains  require  at  least  twenty  minutes  for 
sterilization.  After  being  made  aseptic  the  tubes 
may  be  preserved  in  a  5   per  cent,  solution  of 


DRAINAGE  AND  IRRIGATION.  141 

carbolic  acid.  Bichloride  is  not  be  recommend- 
ed, as  it  forms  chemical  combinations  with  the 
rubber.  The  best  plan,  however,  is  to  boil  the 
tube  in  a  soda-solution  just  before  use. 

Tubes  consisting  of  glass  or  of  hard  rubbei^ 
can  easily  be  rendered  aseptic.  On  account 
of  their  rigidity  they  are  preferred  by  some 
surgeons,  who  claim  that  soft-rubber  drains 
may  be  compressed  in  .the  wound,  thereby  caus- 
ing retention  of  discharges.  The  writer  has 
never  in  practice  experienced  any  retention  of 
pus  which  could  be  traced  to  compression  of  a 
soft  tube.  Whenever  retention  really  occurred, 
it  generally  was  due  to  obstruction  in  the  tube, 
caused  by  thick  or  coagulated  products  of  the 
wound  or  by  other  causes  (see  Section  XII., 
on  Change  of  Dressings).  It  seems  to  the 
writer  that  the  pressure  exerted  upon  a  wound- 
canal  by  a  hard  drain  is  apt  to  cause  sloughing. 
A  great  disadvantage  of  hard  drainage-tubes  is 
that  they  cannot  be  cut  into  proper  lengths,  as 
can  those  consisting  of  soft  rubber,  consequendy 
a  large  variety  of  lengths  of  hard  tubes  must  be 
kept  on  hand. 

Drains  of  decalcified  bone  are  scarcely  used  at 
present.  They  are  unreliable  and  are  often  too 
quickly  absorbed.  Catgut,  silk,  thread,  zvick,  horse- 
hair, and  threads  of  spun  glass  are  used  for  very 
small    drains   ("capillary    drainage"),    the    most 


142  SURGICAL   ASEPSIS. 

valuable  among  them  being  the  wicks,  which  can 
be  made  from  ordinary  lamp-wicks.  The  indica- 
tions for  the  various  forms  of  drainage,  and  its 
technique,  will  be  described  in  Section  X.,  on 
The  Treatment  of  Infected  Wounds,  in  Section 
XL,  on  Open-wound  Treatment,  and  in  Section 
XIL,  on  Change  of  Dressings. 

Schede  recommended  the  utilization  of  the 
moist  blood-clot  which  forms  in  cavities  left  after 
a  piece  of  bone  has  been  removed.  He  unites 
the  outer  edges  of  the  wound  above  the  cavity 
after  it  has  filled  with  blood.  If  aseptic  pre- 
cautions are  taken  the  blood-coagulum  remains 
aseptic  and  will  gradually  be  absorbed.  The 
clot  affords  protection  to  the  raw  surfaces  of 
the  wound,  and  if  it  does  not  contract  and 
desiccate  it  forms  a  nidus  for  granulation-tissue, 
which  develops  and  finally  cicatrizes.  It  is  an 
ideal  method  of  repair,  especially  in  operations 
for  the  removal  of  necrosed  bone  without  re- 
quiring a  drainage-tube. 

Irrigation  Fluid. — Sterilized  water  only  must 
be  used  for  the  washing  of  wounds  or  the  skin 
of  the  patient,  and  the  surgeon  should  wash  his 
hands  in  no  other  liquid,  be  it  mixed  with  an 
antiseptic  or  not.  The  fact  that  underground 
water  is  always  sterile,  showing  the  efficacy 
of  filtration,  has  led  surgeons  to  imitate  nature 
by  selecting  artificially  sterilized   water  for  sur- 


vSURCxICAL     ASEPSIvS. 


Plate  \' 


THE  ASEPTIC   OPERATING-ROOM.  I43 

gical  purposes.  But  no  apparatus  constructed 
on  the  plan  of  natural  filtration  will  furnish  abso- 
lutely sterile  water.  As  indicated  in  Section  III., 
boiling  water  is  the  most  powerful  disinfecting 
agent;  anthrax  spores  exposed  to  it  for  only  two 
minutes  are  invariably  destroyed.  Therefore 
water  which  has  been  boiled  for  five  minutes 
may  safely  be  considered  sterile.  It  is  best  to 
prepare  such  water  shortly  before  the  time  of 
each  operation.  The  water  may  be  preserved, 
however,  if,  after  being  boiled,  it  is  kept  in  clean 
glass  vessels  stoppered  with  sterilized  cotton.  In 
large  hospitals  it  is  advisable  to  have  a  special 
apparatus  for  the  sterilization  of  water.  A  sim- 
ple boiler  in  which  water  can  be  boiled  and  then 
quickly  be  cooled  by  a  system  of  water-pipes 
containing  cold  water  admirably  answers  the 
purpose.  Water  from  deep  wells,  however,  is 
generally  aseptic,  while  stagnant  water  is  loaded 
with  microbes. 


VIII.  THE   ASEPTIC   OPERATING-ROOM. 

The  operating-7^oom  of  a  hospital  {V\.  V.)  should 
be  at  a  considerable  distance  from  the  wards,  to 
avoid  as  much  as  possible  disturbance  to  the  ward 
patients.  The  most  preferable  place  is  the  top 
floor,  as,  besides  the  convenience  mentioned,  good 
light  can  be  obtained  there.     It  is  a  great  conve- 


144  SURGICAL  ASEPSIS. 

nience  to  have  two  smaller  rooms  adjacent  to  the 
operating-room — an  anaesthetizing  room  (PI.  X., 
Fig.  2),  and  another  room  in  which  the  surgeon 
and  his  staff  can  dress  and  disinfect  themselves. 
It  is  also  desirable  to  have  a  store-room  for  the 
materials  required  at  operations.  The  main 
requirement  of  a  strictly  aseptic  operating-room 
is  that  its  floor,  ceiling,  and  walls  may  easily  be 
cleaned.  All  the  objects  in  the  room  should  serve 
none  but  surgical  purposes,  and  should  be  simple 
and  plain.  They  must  be  able  to  withstand 
either  energ^etic  scrubbinor  or  boilino^  in  a  soda- 
solution.  The  floor  must  easily  be  drainable 
and  be  waterproof  Terrazzo  or  marble  is  the 
best  material  for  flooring.  The  walls  should  be 
cemented,  or  at  least  be  oil-painted,  and  the 
corners  of  the  room  should  be  rounded,  so  that 
washing  is  easy. 

On  one  side  there  should  be  several  wash- 
basins supplied  from  hot-  and  cold-water  spigots, 
so  that  either  hot  or  cold  water  may  freely  be 
used.  The  basins  should  be  large  enough  to 
permit  immersion  of  the  hands,  forearms,  and 
elbows.  Arrangements  should  be  made  to  have 
the  water-supply  of  the  pipes  sterilized  before 
it  escapes  from  the  spigots  (see  p.  142).  A 
wash-sink  (with  a  copious  water-supply  and  with 
drip-stones  nearby  for  dishes),  sterilizers,  and 
vessels    for    boiling    water    and    soda-solution, 


THE  ASEPTIC   OPERATING-ROOM.  145 

preferably  seated  on  a  wash-stand  (Fig.  43),  are 
also  required. 

Neuber  advises  that  there  should  be  attached 
to  the  walls  large  glass  shelves  on  which  glass 
bowls  may  be  placed  and  into  which  bowls  the 
water  may  run.     Glass  shelves  are  desirable  at 


Fig.  43. — Simple  wash-stand  for  two  enamelled  dishes  (frame 
wrought  iron,  white-enamel  finish). 

all  events  to  hold  the  glassware,  sponges,  gauze, 
drains,  ligatures,  cotton,  etc. 

Much  has  been  said  about  the  danger  of  spec-. 
tators  being  present  in  an  operating-room.  Some 
surgeons  allow  the  presence  of  spectators  only 
after  they  have  given  assurance  that  they  have 
not  shortly  before  attended  any  case  of  conta- 
gious disease ;  other  surgeons  demand  certain 
10 


146  SURGICAL  ASEPSIS. 

precautions  from  spectators — as,  for  instance, 
that  they  shall  put  on  aseptic  coats ;  and  some 
surgeons  do  not  admit  spectators  at  all.  There 
can  be  no  doubt  that  the  fewer  the  persons  there 
are  in  attendance  the  better  it  is  for  the  patient; 
at  the  same  time,  it  is  in  the  interest  of  humanity 
that  students  be  admitted,  as  the  necessary  expe- 
rience can  be  acquired  only  by  their  presence  as 
frequently  as  possible  at  surgical  operations. 

That  spectators  may  carry  microbes  into  the 
operating-room  on  their  clothing  and  their  bod- 
ies cannot  be  doubted.  After  having  attended 
pathological  rooms,  such  as  sick-rooms  or  even 
autopsy-rooms,  pathogenic  microbes  must  abun- 
dantly adhere  to  the  clothing,  the  hair,  etc.  If 
this  clothing  comes  into  contact  with  an  object 
to  be  used  at  the  operation,  all  aseptic  precau- 
tions previously  taken  may  prove  to  be  valueless. 
The  patient  himself  may  carry  microbes  on  his 
body,  in  the  wound,  or  on  the  dressings.  If  the 
patient's  dressings  be  changed,  fibres  of  gauze  or 
of  cotton  or  scales  of  epidermis  may  be  set  free 
and  be  disseminated  in  the  air,  eventually  to 
settle  upon  some  one's  clothing.  Furthermore, 
when  windows  are  kept  open  a  considerable 
amount  of  dust  containing  organic  substances 
from  the  excretions  of  animals  may  invade  the 
room,  and  settle  upon  an  object  which  may  come 
into  contact  with  a  wound  made  or  to  be  made. 


THE  ASEPTIC   OPERATING-ROOM.  1 47 

Neiiber,  one  of  the  most  distinguished  pio- 
neers of  aseptic  principles,  considers  the  arrange- 
ment of  the  operating-room  to  be  the  main 
requisite  for  success.  He  lays  great  stress  upon 
having  separate  operating-rooms — one  at  least 
for  septic  and  one  for  aseptic  cases,  each  pos- 
sessing separate  furnishings  and  supplies.  There 
can  be  no  doubt  that  it  is  desirable  to  have  at 
least  two  operating-rooms,  and  to  have  the 
arrangements  made  in  the  manner  described 
above.  Although  much  may  be  said  in  favor  of 
Neuber's  theories,  they  cannot  be  sustained  in 
practice ;  and,  fortunately,  the  recent  investiga- 
tions of  Petri  and  Cleves-Symmer  prove  that 
they  are  not  the  sole  essentials  of  success. 

Petri  not  only  fixed  the  special  forms  of  micro- 
organisms suspended  in  the  atmosphere,  but  at 
the  same  time  he  also  ascertained  the  number  of 
microbes  present  in  a  determined  volume  of 
air.  His  method  of  determining  the  presence 
of  7nicro-orga7iisms  consists  in  pumping  a  meas- 
ured volume  of  air  through  a  filter  of  sterilized 
sand.  This  sand  (to  which  all  the  micro-orean- 
isms  of  the  air  adhere)  is  equally  distributed  on 
Petri  plates  containing  sterilized  gelatin.  On 
this  gelatin  the  microbes  multiply  by  forming  as 
many  separate  colonies  as  there  are  microbes, 
which  may  then  be  counted. 

The  next  question  to  be  determined  is  that  of 


148  SURGICAL   ASEPSIS. 

the  7iU7nber  of  microbes  which  will  settle  within 
a  fixed  time  upon  a  wound-surface  of  a  cer- 
tain area.  In  determining  this  question  a  par- 
allelism could  not  be  assumed  between  the  mi- 
crobe-capacity of  the  air  and  the  quantity  of  the 
deposits.  It  would  naturally  be  expected  that  air 
containing  but  few  microbes  would  deposit  but 
few  upon  wounds,  and  vice  versa.  But  it  has 
been  shown  practically  that  this  parallelism  does 
not  always  exist,  as  most  probably  the  microbes 
are  not  equally  distributed  in  the  air,  some  regions 
being  densely  and  others  sparsely  populated. 
This  fact  can  best  be  shown,  according  to  Cleves- 
Symmer,  if  several  gelatin  plates  are  exposed 
at  the  same  time  and  the  different  plates  are 
kept  in  the  same  part  of  the  room.  A  great 
difference  as  regards  quantity  and  quality  will 
then  be  found,  for  neither  the  same  kind  nor 
the  same  quantity  of  microbes  will  settle  upon 
the  plates. 

Cleves-Symmer  exposed  gelatin  plates  for 
seven  days  simultaneously  in  three  surgical 
wards.  This  exposure  was  made  five  times  a 
day,  the  first  at  5  a.  m.,  while  the  patients  were 
asleep,  and  the  second  at  7  a.  m.,  after  the  floors 
were  first  washed  and  then  scrubbed.  Similar 
exposures  were  made  at  9  a.  m.,  when  operations 
were  generally  performed,  and  the  last  exposure 
was  made  late  in  the  afternoon.     The  sterile  gel- 


THE   ASEPTIC   OPERATING-ROOM.  I49 

atin  was  contained  in  round,  flat,  large-surface 
Petri  dishes.  After  the  dishes  had  been  exposed 
each  time  for  twenty  minutes  they  were  covered 
and  preserved  in  a  moist  incubator  the  temper- 
ature of  which  was  that  of  the  room.  The 
developing  colonies,  as  soon  as  they  could  be 
recognized  by  the  naked  eye,  were  counted 
daily,  and  were  observed  so  long  as  they  could 
be  distinguished  from  one  another.  Among 
4613  microbes  so  counted  there  was  found  but 
one  pathogenic  micro-organism,  which  was  the 
bacillus  pyocyaneus. 

At  a  time  when  nearly  every  third  case  in  the 
hospital  suffered  from  a  wound  in  the  discharge 
of  which  this  bacillus  was  contained  there  were 
certainly  ample  opportunities  for  it  to  permeate 
the  air;  if,  despite  this,  a  pathogenic  microbe  was 
found  but  once,  it  is  proof  enough  that  the  air 
necessarily  contains  very  few  pathogenic  mi- 
crobes. The  writer's  experience  in  St.  Mark's 
Hospital,  New  York,  accords  with  this  proposi- 
tion. The  average  results  of  operations  in  its 
old  building,  the  very  poor  accommodations  in 
which  premised  all  the  elements  of  atmospheric 
infection,  were  nearly  as  good  as  those  obtained 
in  the  well-equipped  new  building. 

The  operating-rooms  of  Billroth  at  the  old 
"Allgemeines  Krankenhaus  "  in  Vienna  were  far 


150  SURGICAL   ASEPSIS. 

from  being  an  anti-Infectious  ideal.  The  same  re- 
mark applies  to  the  greater  majority  of  the  prom- 
inent European  hospitals — for  instance,  the  cele- 
brated Albert  Amphitheatre  in  Vienna,  and  the 
clinic  of  the  eminent  surgeon  Gussenbauer  in 
Prague,  as  well  as  the  surgical  workshops  which 
the  writer  saw  in  some  Italian  hospitals. 

Success,  fortunately,  depends  not  upon  the 
marble  floor  of  a  modern  operating-room  and 
upon  more  or  less  complicated  apparatus,  but 
upon  carrying  out  the  principles  of  asepsis  so  far 
as  direct  contact  with  wounds  is  concerned.  This 
fact  explains  why,  under  the  most  unfavorable 
circumstances,  Bassini  in  Padua  was  able  to  per- 
form hundreds  of  herniotomies  in  succession 
without  meeting  with  a  single  fatal  result.  At 
the  new  St.  Mark's  Hospital,  which  really  merits 
the  designation  of  a  "  model  hospital,"  particularly 
with  reference  to  modern  aseptic  appliances,  the 
death-rate  is  now  about  the  same  as  it  was  in 
the  old  hospital.  This  uniformity  must  certainly 
be  due  only  to  the  rigid  observation  of  aseptic 
principles  in  reference  to  all  objects  that  come  into 
contact  zvith  the  wound,  such  ds  the  hands  of  the 
surgeon,  the  instruments,  and  the  field  of  operation. 
One  of  the  gynecologists  at  the  old  St.  Mark's 
Hospital  two  years  ago,  under  very  minute  asep- 
tic precautions,  performed  three  hundred  lap- 
arotomies  in    succession   with   a   mortality   of  8 


THE  ASEPTIC   OPERATING-ROOM.  151 

per  cent.  If,  as  this  rate  shows,  asepsis  depends 
not  upon  aseptic  operating-rooms,  but  mainly 
upon  minute  precautions  in  reference  to  the  con- 
tact question,  there  is  no  reason  why  success 
should  not  be  obtained  in  the  poorest  abode. 
The  whole  matter  converges  to  one  point — 
namely,  that  operations  performed  in  a  tenement- 
house  entail  a  great  deal  more  trouble  to  the 
surgeon,  while  in  a  hospital  everything  can  be 
carried  out  with  the  greatest  convenience.  It  is 
quite  natural,  therefore,  that  a  surgeon,  when  he 
has  the  choice,  prefers  operating  in  a  hospital. 

If  after  a  laparotomy  the  patienf  s  abdo^nen  has 
been  closed,  his  fate  is  determined,  and  the  condi- 
tion of  the  surrounding  atmosphere  will  be  a 
matter  of  indifference.  If  the  operation  was  not 
done  aseptically,  no  kind  of  after-treatment,  nor 
any  secondary  opening  of  the  cavum  abdominis, 
will  remedy  this  omission.  If  danger  of  infection 
really  threatened  from  the  air,  the  danger  would 
naturally  be  greater  in  hospitals,  which  shelter 
many  more  microbes,  than  in  a  dwelling-house. 

In  private  practice  it  would  be  advisable  to 
select  a  laree  room  with  orood  lior-ht  for  an 
operating-room.  If  possible,  there  should  be 
another  room  for  the  occupancy  of  the  patient 
after  operation.  Many  surgeons  recommend  the 
removal  of  all  furniture,  paintings,  carpet,  etc. 
They  even  go  so  far  as  to  wash  the  walls  with 


152  SURGICAL   ASEPSIS. 

bichloride  and  to  scrub  them  afterward  with 
crumbs  of  bread  (E.  von  Esmarch).  If  these 
procedures  are  undertaken  a  day  or  two  before 
the  operation,  nothing  can  be  said  against  them, 
but  if  they  are  done  only  a  few  hours  before  the 
operation,  they  certainly  are  apt  to  impregnate 
the  atmosphere  with  many  more  microbes,  for 
these  procedures  whirl  up  dust,  which  under  such 
circumstances  may  become  a  potent  carrier  of 
micro-organisms.  Therefore  it  is  by  all  means 
preferable  to  leave  the  operating-room  undis- 
turbed shortly  before  operating,  and  to  exercise 
great  care  that  the  tables  and  chairs,  and  what- 
ever else  may  be  required  for  operation,  are 
covered  with  sterilized  sheets  or  towels.  If  ster- 
ilized linens  are  not  obtainable,  freshly  washed 
and  ironed  sheets  will  do  for  all  covers  which  do 
not  come  into  direct  contact  w^th  the  field  of 
operation. 

The  operating-table,  and  also  the  small  tables 
upon  which  instruments  are  put,  should  be  con- 
structed of  glass  and  iron,  so  that  they  may 
easily  be  cleaned  with  a  hot  soda-solution  or  be 
sterilized  in  a  large  steam-apparatus.  Chairs 
upon  which  instruments,  etc.  are  put  should 
consist  of  enamelled  iron  also.  Operating-tables 
should  always  be  made  of  plain,  smooth  material, 
and  should  not  contain  any  grooves  or  ornamen- 
tation.    Their  tops  should  be  either  of  metal  or 


THE  ASEPTIC   OPERATING-ROOM. 


153 


of  plate  glass.  Numerous  tables  of  this  kind, 
all  more  or  less  useful,  have  been  devised,  those 
recommended  by  Korte  (Fig.  44),  Sonnenburg, 
and  Edebohls  being  especially  desirable.  If  such 
tables  are  not  available,  an  ordinary  strong 
kitchen  table  may  be    utilized,  after  thoroughly 


Fig.  44. — Korte's  general  operating-table,  with  foot-lever  to  set  table  on 
casters;  iron  top,  white-enamel  finish,  slanting  to  the  centre,  with  a  metal 
gutter  for  drainage  ;  two  detachable  drop-plates  for  operating  on  the  lower 
limbs ;  side  table  for  operating  on  the  arm  and  hand. 

scrubbinor  it  with  hot  soda-solution.  An  attach- 
ment  for  Trendelenburg's  position,  such  as 
advised  by  Cleveland,  Boldt,  Edebohls,  Krug, 
and  others,  is  desirable. 

When  economical  considerations  must  guide 
the  surgeon,  Leopold's  simple  and  inexpensive 
attachment    may  be  used.     It    is    a    frame  (fifty 


154 


SURGICAL   ASEPSIS. 


inches  in  length  and  twenty  inches  in  width)  con- 
structed with  a  hinged  flap  whose  lower  part — 
that  is,  the  part  upon  which  the  legs  rest — can  be 
brought  downward,  thus  forming  a  right  angle 
with  the  upper  flap,  upon  which  the  pelvis  and 
thighs  rest.  The  flap  can  be  raised  sufficiently 
high  by  a  support.  This  entire  frame  can  easily 
be  fastened  to  any  kind  of  table  by  means  of  iron 
clamps. 

The  operating-table    should  be    covered  with 
a  folded  blanket,  a  muslin  sheet,  and  a  sheet  of 


Fig.  45.— Ordinary  dressing-  and  instrument-table,  wrought  iron,  white- 
enamel  finish. 


rubber  or  of  oil-cloth.  Such  sheets  may  be  so 
pinned  together  as  to  form  a  funnel  leading  into 
a  pail  at  the  lower  part  of  the  table.  Kelly's  in- 
flatable rubber  cushion  may  be  used  for  this  pur- 
pose.    In  its  newest  form  the  anterior  apron  is 


THE  ASEPTIC  OPERATING-ROOM. 


155 


doubled  into  a  large  funnel  for  conducting  the 
discharges  into  the  pail. 

The  instruments  used  during  an  operation 
may  be  placed  upon  an  ordinary  table  made  of 
glass  and  iron  (Fig.  45).  An  instrument- table 
which  is  especially  useful  in  hospital^  practice 
combines  a  glass  case  for  aseptic  dressings 
with  a  lifting-top  cover  and  a  hinged  side  shelf 
(Fig.  46). 


5i'** 


Fig.  46. — Kny's  instrument-table. 


The  instruments  of  a  hospital  should  be 
kept  in  an  instrument- cabinet  composed  of  iron 
and  glass  (as  shown  in  Fig.  47),  which  may  be 
cleaned    easily   and    thoroughly.      The    shelves 


iS6 


SURGICAL  ASEPSIS. 


must  consist  of  plate  glass,  and  should  be  ar- 
ranged in  such  a  manner  that  they  may  be 
pulled  out  separately. 

Splints  and  apparatus  like  Volkmann's  sleigh, 
etc.  should  be  kept  in  an  adjoining  room. 

Irrigators  are  being  more  and  more  discarded. 
Whenever  it  is  possible  mechanically  to  remove 


Fig.  47. — Kny's  instrument-cabinet  with  adjustable  shelves:   a  plate-glass 
partition  in  the  centre  practically  divides  it  into  two  closets. 

from  a  wound  coagula,  necrotic  tissue,  granula- 
tions, etc.  by  wiping  them  from  the  wound  with 
gauze  mops,  this  method  is  preferable  to  irriga- 
tion. Irrigation,  it  is  true,  removes  blood-coagula 
and   secretions  and   brings   bactericidal   medica- 


THE  ASEPTIC   OPERATING-ROOM.  I  57 

ments  into  contact  with  the  wound,  but  at  the 
same  time  it  is  apt  not  alone  to  remove  pus  and 
infectious  secretions,  but  also  to  force  such  sub- 
stances into  the  tissues,  so  that  further  infection 
is  favored  rather  than  prevented. 

In  an  infected  wound  the  micro-oro-anisms  are 
sheltered  by  either  the  wound-surface,  the  blood- 
coagula,  the  necrotic  tissue,  or  the  crusts  covering 
the  wound-^ — namely,  with  material  that  can  never 
be  disinfected  by  the  commonly-used  so-called 
"antiseptic  solutions."  In  large  cavities  where 
mechanical  cleaning  from  fibrinous  or  cheesy 
masses  is  indicated — as  in  pyothorax,  for  in- 
stance— the  use  of  an  irrigator  is  desirable  at 
the  time  of  operation,  while  later  on,  when  such 
solid  masses  are  removed,  no  further  mechanical 
cleaning  will  be  necessary.  In  plastic  operations, 
especially  on  the  vagina,  irrigation  is  also  desir- 
able, as  it  dispenses  with  sponging  there. 

The  irrigator  should  always  be  made  of  glass, 
and  the  scrupulous  cleansing  of  its  rubber  tube 
is  of  very  great  importance.  A  thermometer 
should  be  connected  with  it,  so  that  the  tem- 
perature can  always  be  ascertained  without  the 
unreliable  guess  of  a  helping  hand.  If  opera- 
tions are  performed  aseptically  and  as  dry  as 
possible,  mechanical  cleaning  with  an  irrigator  is 
hardly  necessary.  For  an  irrigator  there  may 
be  substituted  a  graduated  glass  jar,  which  can 


158  SURGICAL  ASEPSIS. 

be  sterilized  very  easily,  as  it  does  not  require 
any  attachments. 

Large  pails  should  always  be  ready  in  the 
operating-room  to  receive  the  removed  dressings 
or  other  waste  material,  which  should  never  be 
thrown  on  the  floor.  It  is  desirable  to  have  such 
pails  removed  from  the  operating-room  as  soon 
as  they  have  done  service. 

Each  patient,  immediately  after  entering  the 
hospital,  should  have  a  bath.  This  bath  is  an  im- 
portant preliminary  operation  before  local  disin- 
fection is  begun.  Bath-tubs  (enamelled  ones  are 
best)  should  therefore  be  at  hand  in  abundance. 

The  wards  and  the  private  rooms  in  a  hospital 
should,  as  suggested  by  the  principles  enunciated 
above,  be  so  arranged  that  they  can  always  easily 
be  cleaned.  Halls  and  floors  should  consist  of 
the  same  material  as  that  used  in  the  operating- 
rooms.  Beds,  tables,  and  chairs  should  mainly 
be  constructed  of  iron.  Horse-hair  mattresses 
and  Ii7ie7i  sheets  should  be  used  to  the  exclusion 
of  all  other  bed-clothing.  If  available,  two  beds 
should  be  used  for  the  same  patient,  as  it  usually 
adds  gready  to  his  comfort  to  move  him  from 
one  bed  into  another.  Good  ventilation  is  essen- 
tial. The  temperature  should  be  kept  uniform. 
From  time  to  time  the  wards  and  the  private 
rooms  should  be  disinfected  thoroughly,  whether 
they  ever  contained    an   infectious  case  or  not. 


ASEPTIC   WOUNDS.  1 59 

Mechanical  cleansing,  as  shown  on  page  6i,  is 
the  most  important  and  powerful  part  of  disin- 
fection. After  the  floor,  the  walls,  and  the  ceil- 
ings, as  well  as  the  doors,  windows,  bedsteads, 
tables,  and  other  objects,  have  been  scrubbed 
with  hot  soda-solution,  they  should  be  washed 
with  hot  water.  The  bedding,  curtains,  etc.  must 
be  sterilized  either  with  boiling  water  or,  prefer- 
ably, with  steam.  The  rooms  and  their  utensils 
should  be  aired  for  several  days  before  use. 


IX.  ASEPTIC  WOUNDS. 

Primary  union  is  the  ideal  toward  which  the 
surgeon  strives  in  treating  wounds.  This  ideal 
can  be  attained  only  when  strict  aseptic  precau- 
tions have  been  observed. 

Primary  union  occurs  after  the  walls  of  a 
wound  have  been  adjusted  accurately  and  a 
moderate  amount  of  exudation  has  taken  place, 
resulting  in  the  formation  of  fibrin,  which  tem- 
porarily glues  together  the  edges  brought  into 
apposition.  If  the  parts  have  not  been  adjusted 
carefully,  blood-corpuscles  and  masses  of  coag- 
ulated fibrin  form  wherever  the  walls  have  not 
come  accurately  into  contact.  Such  exudations 
may  organize  (moist  blood-clot,  Section  VII.,  p. 
142),  but  in  most  cases  they  impede  the  healing 
process  just  the   same  as  fragments  of  bruised 


l6o  SURGICAL   ASEPSIS, 

and  injured  tissue  may  undergo  necrosis  in  con- 
sequence of  impairment  of  their  blood-supply. 
To  prevent  the  accumulation  of  blood  in  a 
wound  it  is  essential  to  stop  the  bleeding  so 
thoroughly  that  the  wound-surfaces  appear  abso- 
lutely dry  before  they  are  united. 

To  prevent  the  formation  of  necrotic  tissue  all 
bruised  or  injured  tissue  should  be  removed,  to 
ensure  smooth  coaptation  of  the  wound-surfaces. 
When  an  incision  has  been  made  through  the 
superficial  tissues,  the  margins  of  the  wound 
separate  according  to  the  elasticity  of  the  various 
structures  that  have  been  divided  by  the  incision  ; 
larger  vessels  must  be  caught  by  forceps  and 
be  ligated.  Hemorrhage  from  small  vessels  soon 
stops  without  artificial  help,  as  their  lumen  will 
close  by  contraction  of  their  walls,  and  the  arte- 
ries will  retract  into  their  sheaths.  Total  ob- 
struction then  follows  by  the  formation  of  a 
blood-clot  within  the  vessels.  After  the  vicinity 
of  a  wound  has  been  washed  with  sterilized  water 
and  the  surface  of  the  wound  has  been  wiped 
off  carefully  with  gauze  mops,  the  bleeding  will 
cease  entirely,  and  then  the  edges  may  be  united 
by  sutures.  In  very  large  wounds,  where  more 
than  the  usual  amount  of  discharge  is  natu- 
rally anticipated,  deep  (buried)  sutures  must  be 
employed  to  maintain  the  deeper  surfaces  in 
apposition.      If  this  procedure    is   omitted,   the 


ASEPTIC   WOUNDS.  l6l 

accumulation  of  the  discharge  will  separate  the 
opposing  surfaces.  Sometimes  pressure  alone 
may  answer  for  this  purpose,  and  sometimes 
gauze  drainage ;  and  exceptionally  a  rubber 
drainage-tube  into  each  corner  of  the  wound 
will  be  required  to  conduct  off  the  wound-product 
so  that  the  united  surfaces  may  remain  adherent. 

In  the  regular  course  very  slight,  if  any,  swell- 
ing of  the  lips  of  the  wound  will  follow.  The 
tissue  in  the  vicinity  of  the  incision  may  be  some- 
what firmer  than  in  its  natural  condition.  This 
firmness  is  due  to  the  disturbance  in  the  circula- 
tion followinof  the  severinof  of  the  blood-vessels. 
There  should  be  no  discoloration,  especially  no 
hyperaemia,  of  the  wound-surface. 

An  occluded  wound,  very  naturally,  is  better 
guarded  against  infection  than  an  open  wound. 
But  if  microbes  have  invaded  a  wound  during 
operation,  or  if  there  supervene  any  of  the 
occurrences  above  described,  occlusion  may  be 
detrimental  to  the  patient,  as  blood-clots,  as  well 
as  necrotic  tissue  and  the  wound-products,  are 
the  most  favorable  soil  for  pathogenic  microbes. 
Whenever  there  is  doubt  as  to  the  invasion  of 
microbes,  it  is  better  to  omit  suturing  and  to 
follow  the  principles  explained  in  Section  X. 
concerning  Infected  Wounds,  and  those  of  Sec- 
tion XL,  on  Open-wound  Treatment.     When  it 

can  be  ascertained  that,  despite  strict  aseptic  pre- 
11 


1 62  SURGICAL   ASEPSIS. 

cautions,  abundant  discharge  is  to  be  expected, 
or  when  during  operation  a  microscopic  exam- 
ination has  revealed  the  presence  of  virulent 
microbes,  the  introduction  of  small  drainage- 
tubes,  or  preferably  of  lamp-wicks  inserted  into 
the  edores  of  the  wound  or  carried  throucrh  coun- 
ter-openings,  is  indicated.  Whenever'  doubt  exists 
as  to  the  kind  of  after -ti^ eat ment,  the  decision  sJiould 
be  in  favor  of  drainage.  The  possibility  of  thor- 
oughly arresting  hemorrhage  as  well  as  prevent- 
ing the  formation  of  pockets  rests  entirely  in  the 
hands  of  the  surgeon.  Aseptic  treatment,  how- 
ever, allows  no  irritation  of  wounds,  consequently 
the  discharge  is  generally  very  scanty. 

An  excellent  technique  of  uniting  aseptic 
wounds,  as  advised  by  Neuber,  is  as  follows: 
After  having  loosely  packed  the  whole  wound 
with  moist  sterilized  gauze  the  wound-flaps  are 
united  above  it  by  sutures.  Small  wounds  re- 
quire only  a  strip  of  gauze.  The  edges  of  the 
wound  are  then  very  carefully  adjusted,  except 
at  the  lowest  part  of  the  wound,  where  it  is  left 
sufficiently  open  to  allow  the  gauze  strip  to  pro- 
trude. While  an  assistant  presses  a  few  sponges 
on  the  united  surfaces  the  gauze  is  slowly  pulled 
out  from  the  interior  of  the  wound-surfaces. 
This  crauze  is  now  saturated  with  blood  which 
has  been  oozing  while  the  sutures  were  applied. 
If  it  should  happen  that  a  few  fibres  remain  when 


ASEPTIC    WOUNDS. 


163 


the  gauze  is  pulled  out,  these  fibres  will  become  en- 
cysted in  the  wound  without  causing  any  reaction. 
Forcible  compression  by  sponges  covering  the 
united  wound-surface  is  then  used  once  more,  to 
squeeze  from  the  wound-surface  all  the  blood  still 
contained  between  the  interior  wound-surfaces. 
By  drawing  together  the  sutures  which  have  pre- 
viously been  applied  the  wound  is  closed  entirely, 
and  it  is  then  covered  with  sterilized  gauze. 

If  the  raw  surfaces  are  of  an  irregular  shape, 
so  that  a  considerable  amount  of  pressure  is 
required  to  keep  them  in  contact,  it  is  advisable 
to  fasten  marine-sponges,  enveloped  in  sterilized 
gauze,  to  the  wound   by  gauze  bandages. 

To  secure  primary  union  mastering  of  the 
technique  of  suturing  is  essential.  Of  the  many 
methods  advised,  the  following  may  be  mentioned. 

Continued  Suture. — The  most  desirable  method 
of  suturing  is  by  the  con- 
tinued or  glover's  stitch, 
as  it  can  be  applied 
very  rapidly.  The  edges 
of  the  wound  can  also 
be  adjusted  very  easily 
when  this  suture  is  used. 
When  possible,  only 
straight,  spear-shafted  needles,  of  the  size  ordi- 
narily used  by  tailors,  should  be  employed.  The 
thread   should  not  be   very  long,  a   knot  being 


Fig.  48. — Continued  suture  with 
relaxation-sutures. 


164  SURGICAL  ASEPSIS. 

fixed  at  one  of  its  ends.  The  needle  must  be 
inserted  at  one  end  of  the  wound  and  about  one- 
third  of  an  inch  from  its  edge,  which  may  be  seized 
by  strong  mouse-toothed  forceps.  The  first  su- 
ture may  be  appHed  as  an  interrupted  suture, 
but  without  cuttinor  the  threads  after  the  knot  is 
tied,  or  the  procedure  may  be  carried  out  in 
the  same  manner  as  the  ordinary  tailor-stitch 
is  made. 

The  needle  is  first  carried  through  one  lip  of 
the  wound  and  then  through  the  other,  where  a 
loop  is  formed,  through  which  the  end  of  the 
thread  is  drawn  so  that  it  can  be  fixed  in  a  knot. 
If  desirable,  a  small  gap  about  one-third  of  an 
inch  in  length  may  be  left  for  drainage.  If  the 
wound  is  very  long,  the  continuous  suture  may 
be  interrupted  by  making  loops  at  intervals  of 
three  or  four  inches.  In  long  wounds,  or  Avhere- 
ever  any  considerable  amount  of  tension  exists, 
it  is  advisable  to  apply  relaxation-siitui'es  at  inter- 
vals of  one  and  a  half  inches  in  addition  to  the 
continued  suture  (Fig.  48).  For  such  sutures  the 
needle  should  be  introduced  three-fourths  of  an 
inch  from  the  ed<:re  of  the  wound.  While  it  is 
convenient  to  use  catgut  for  continuous  sutures, 
provided  it  is  not  applied  in  cavities  like  the  peri- 
toneum (see  p.  132),  the  relaxation-suture  should 
always  be  of  strong  silk.  The  continuous  suture 
is  especially  valuable  in  those  cases  where  sue- 


ASEPTIC   WOUNDS. 


■165 


cess  greatly  depends  upon   rapidity,  as  in  opera- 
tions on  the  peritoneum  and  the  intestines. 

The  interi'ttpted  suture  (Fig.  49)  is  the  one  most 
commonly  used.  It  can  be  appHed  with  either 
straight  or  curved  needles.  Catgut  or  silk  may 
be  used,  according  to  the  principles  of  Section  VI. 
One  edee  of  the  wound  is  seized  with  mouse- 
tooth  forceps  and  is  perforated  with  the  needle ; 
then  the  same  manoeuvre  is  repeated  on  the  op- 
posite side.  If  there  is  little  tension,  an  assistant 
may  so  approximate  the  wound-edges  that  with 
one  stitch  both  edges  may  be  transfixed  at  the 
same  time.  The  knot  of  the  suture  should  always 
be  applied  laterally 
from  the  wound.  Su- 
tures should  not  be 
applied  too  tightly,  as 
tension  may  produce 
irritation,  necrosis,  and 
abscesses  in  the  stitch- 
holes.  If  there  be  any  tension,  however,  It  Is 
advisable  to  intertwist  the  ends  of  the  thread 
twice,  makino-  a  suro-Ical  knot. 

The  suturing  should  always  begin  at  the  middle 
of  the  wound,  and  not  at  its  ends,  especially  in 
long  wounds,  as  the  edges  may  be  adjusted  much 
more  easily  if  done  in  the  former  way.  As  a 
rule,  about  three  stitches  to  the  inch  should  be 
used.     The  needle  should  be  introduced  about  a 


Fig.  49. — Interrupted  suture. 


1 66  SURGICAL  ASEPSIS. 

quarter  of  an  inch  from  the  edge  of  the  wound. 
If  relaxation-sutures  be  required,  they  must  be 
appHed  first;  in  making  them  the  needle  should 
be  introduced  at  least  half  an  inch  from  the  edees 
of  the  wound.  In  long  wounds  relaxation-sutures 
may  serve  as  sitiiation-s2Uures — that  is,  they  may 
answer  the  purpose  of  landmarks.  Perfect  ap- 
proximation is  always  of  the  greatest  importance. 

If  even  a  minute  portion  of  the  ^d^<g^.  of  a 
wound  be  turned  inward  because  of  imperfect 
edge-adjustment,  necrosis  of  this  small  area  may 
occur  and  may  be  the  indirect  cause  of  further 
pathogenic  processes  which,  under  unfortunate 
circumstances,  may  lead  even  to  the  death  of 
the  patient.     (Compare  Section  XII.,  p.  230.) 

The  silver-wire  suture  is  very  valuable  in 
suturinof  bone-fraofments,  and  sometimes  for 
relaxation-sutures.  The  writer  found  it  very 
useful  in  operations  on  the  tongue  and  the  lips, 
as  a  prophylactic  suture.^  In  operations  upon 
the  lips  it  is  of  particular  importance  to  reduce 
the  amount  of  hemorrhage  to  a  minimum,  be- 
cause those  concerned  in  these  operations,  which 
are  generally  done  either  for  hare-lip  or  for  epi- 
thelioma, are  babies  or  aged  individuals — that 
is,  delicate  and  feeble  patients,  in  whom  even  a 
moderate    amount   of   hemorrhage   may   be   fol- 

»  "  Ueber  Ilasenscharten-Operationen,"  New  Yorherviedicinische  Presse, 
March,  1888. 


ASEPTIC   WOVA^DS.  1 6/ 

lowed  by  deleterious  consequences.  Based  upon 
this  experience,  the  writer  has  advised  in  such 
cases  a  prophylactic  suture,  the  idea  being  to 
apply  a  suture  before  any  cutting  has  been  done 
(Fig.  50).  The  technique  is  the  following:  Hav- 
ing planned  the  lines  of  incision,  the  integument 
is  pricked  with  a  sharp  knife  as  a  guide  for  the 
subsequent  incisions.  An  Emmet  blunt  needle 
(a  sharp  needle  might  cause  excessive  bleeding) 
armed  with  a  wire  is  then  introduced,  and  hangs 
down  like  a  sling,  so  that  it  cannot  interfere  with 
the  incision.  Then  an  assistant  seizes  the  flap 
with  his  thumb  and  index  finger,  the  flap  is  cut 
out  as  indicated  by  the  preliminary  incision,  the 
edges  are  pulled  together  quickly,  and  the  wire 
is  twisted,  thus  checking  the  hemorrhage  imme- 
diately. After  this  it  is  very  easy  to  do  what- 
ever trimming  is  necessary.  In  case  an  exact 
approximation  has  not  been  obtained,  another 
wire  suture  may  be  applied  in  a  better  position, 
the  first  one  being  taken  out.  The  prophylactic 
suture  may  then  serve  as  a  relaxation-suture 
(Fig.  51).  If  another  incision  should  be  re- 
quired, it  is  easily  done,  and  the  bleeding  can 
occur  only  during  the  time  of  making  the 
incision.  The  main  advantage  of  silver  wire  is 
that  it  can  easily  be  made  sterile  by  simple  boiling. 
On  other  suture  material  compare  Section  VI. 
In  deep  wounds  subcutaneous  or  buried  sutures 


i68 


SURGICAL   ASEPSIS. 


are  often  necessary.  In  making  buried  sutures 
each  layer  beneath  the  integument  must  be  sewn 
separately,  so  that  the  surfaces  of  the  wound,  as 
well  as  the  skin,  can  be  adjusted  properly.  Thus 
pockets  are  avoided,  and  divided  structures,  such 

as  tendons,  nerves,  mus- 
^^^^^  cles,    aponeuroses,    and 

fasciae,  may  be  united.  It 
should  always  be  borne 
in  mind  that  exact  sutur- 
ing is  an  integral  part  of 
aseptic  treatment.    After 


Fig.  50. — Beck's  prophylactic 
suture. 


Fig.  51. — Prophylactic  suture  as 
relaxation-suture. 


suturing,  the  whole  area  should  be  covered  with  a 
layer  of  aseptic  gauze,  then  with  cotton  or  moss. 
Immobilization  is  naturally  of  great  import- 
ance. Where  moss-board  (Fig.  34)  is  not  strong 
enough  to  answer  this  purpose,  splints  consisting 
of  wire  or  of  plaster  of  Paris  must  be  employed. 
After  such  operations  as  laparotomies,  wherein 
splints  for  immobilization  naturally  cannot  be 
used,  they  must  be  imitated  by  administering 
morphine  to  arrest  peristalsis,  etc.     Immobiliza- 


ASEPTIC   WOUNDS.  1 69 

tion  can  sometimes  be  carried  out  by  surround- 
ing the  dressing  of  large  wounds  with  a  plaster- 
of-Paris  bandage.  If  the  patient  is  restless,  such 
bandao^es  should  be  used  around  the  abdomen 
and  both  legs,  especially  after  operations  such 
as  those  for  inguinal  or  femoral  hernia. 

If  all  the  above  rules  are  carefully  observed, 
hardly  any  disturbances,  under  ordinary  circum- 
stances, will  be  noticed.  The  dressing  may,  as 
a  rule,  remain  unchanged  until  recovery.  The 
patient's  pain,  if  any  follows  the  operation,  usu- 
ally ceases  on  the  subsequent  day,  and  the  most 
that  is  complained  of  is  a  slight  sensation  of  dis- 
comfort. As  soon  as  the  nausea  and  headache 
following  anaesthesia  have  passed  off,  the  patient 
should  regain  his  appetite  and  be  able  to  sleep, 
and  he  should  feel  as  in  his  normal  state.  A  con- 
tented expression  of  a  patient  on  the  day  follow- 
ing laparotomy  generally  presages  a  favorable 
course  for  the  case. 

Aseptic  w^ounds  treated  as  described  above 
heal  more  rapidly  than  those  which  are  united 
without  using  pressure  or  those  in  which  drain- 
age has  been  employed.  Another  advantage  of 
the  aseptic  method  is,  that  if  wounds  heal  under 
one  simple  dressing,  there  can  be  no  danger  of 
secondary  infection  by  changing  the  dressing. 
And  even  when  infection  has  possibly  been 
avoided   in   renewing  the   dressings  the  wound 


170  SURGICAL   ASEPSIS. 

will  be  irritated  greatly — a  fact  which  manifests 
itself  generally  by  a  slight  elevation  of  temper- 
ature shortly  afterward.  While  under  the  old 
antiseptic  treatment  about  two-thirds  of  the 
cases  showed  an  elevation  of  temperature,  this 
phenomenon  is  observed  only  in  one-third  of  the 
cases  treated  aseptically  as  described  above. 

The  characteristic  features  of  this  so-called 
aseptic  fevei'  are  as  follows  :  It  generally  sets  in 
immediately  after  the  operation  has  been  per- 
formed, while  septic  fever  usually  does  not  begin 
before  the  day  following  the  operation  ;  the  tem- 
perature in  aseptic  fever  ordinarily  does  not  ex- 
ceed 102^°  F.,  but  may  exceptionally  rise  even 
to  104°  F.,  precisely  as  in  septic  fever,  but,  by 
constantly  decreasing,  aseptic  fever  ceases  in  two 
or  three  days  ;  furthermore,  in  aseptic  fever  the 
pulse  is  regular  and  strong  and  rarely  exceeds  1 10. 

Aseptic  fever  is  due  to  the  absorption  of  fibrin 
ferment,  a  substance  which  can  be  obtained  arti- 
ficially from  defibrinated  blood.  If  this  ferment 
is  injected  into  animals,  it  causes  coagulation  of 
the  blood,  and  generally  death.  Fibrin  ferment 
is  produced  by  the  breaking  down  of  minute  por- 
tions of  the  wounded  tissues,  especially  of  blood- 
coagula.  This  explains  why  the  fever  caused  by 
the  ferment  sets  in  immediately  after  operation, 
while  in  an  infected  wound  the  pathogenous 
microbes  which  invaded  the  wound  develop  and 


INFECTED    WOUNDS.  I7I 

multiply  comparatively  slowly,  thereby  producing 
the  ptomaines  whose  absorption  causes  septic 
fever.  It  must  be  assumed  that  one  or  a  few 
microbes  do  not  necessarily  cause  any  symptoms 
of  infection,  as  the  vitality  of  the  tissues  may  be 
able  to  destroy  such  a  small  number,  but  that 
the  symptoms  become  perceptible  as  soon  as  the 
microbes  are  produced  in  quantities  and  toxines 
form  accordingly. 

During  the  twenty-four  hours  following  an 
operation  a  distinct  prognosis  as  to  the  course 
of  the  wound  cannot,  as  a  rule,  be  given,  but 
after  this  time,  if  symptoms  of  infection  remain 
absent,  it  can  be  assumed  that  no  disturbance 
will  follow.  It  is  only  in  exceptional  cases  that 
symptoms  of  infection  develop  later.  Such  late 
infections  are  supposed  to  be  due  to  poor  ob- 
servance of  aseptic  precautions  while  removing 
the  dressings. 


X.  INFECTED  WOUNDS. 

While  it  should  nearly  always  be  possible  to 
prevent  infection  of  a  wound  made  by  the  sur- 
geon, it  is  practically  impossible  thoroughly  to 
disinfect  a  wound,  in  the  common  sense  of  the 
word,  after  infection  has  occurred.  It  is  quite 
easy  to  sterilize  an  instrument  or  a  towel  in  boil- 
ing water  or  in  steam,  but  it  is  impossible  to  use 


1/2  SURGICAL    ASEPSIS. 

such  Strong  disinfecting  agents  on  human  tissue  ; 
nor  can  antiseptic  solutions,  even  if  they  could  be 
borne  in  full  strength,  directly  permeate  tissues 
which  have  been  invaded  by  microbes.  Wound- 
products  containing  a  considerable  amount  of 
albumen  combine  with  the  antiseptic  solution, 
thus  weakenino-  or  even  annulling  its  influ- 
ence.  Furthermore,  as  demonstrated  in  Section 
III.,  considerable  harm  may  be  done  the  tissues 
by  using  strong  antiseptics,  as  the  microbes  can 
much  better  withstand  antiseptic  drugs  than  can 
the  tissues.  If  even  only  so  weak  a  solution  as 
one  of  3  per  cent,  of  carbolic  acid  be  used  on  a 
wound,  its  surface  loses  its  red  color  and  turns 
gray,  evincing  superficial  necrosis  of  the  tissues. 
With  reference  to  the  toxic  influence  of  strong 
antiseptics,  it  must  be  borne  in  mind  also  that  an 
infected  patient,  who  is  consequendy  more  or  less 
debilitated,  is  thus  less  able  to  resist  poisonous 
drugs  than  is  a  non-infected  one.  • 

As  before  stated,  surgeons  are  not  yet  In  pos- 
'sesslon  of  drugs  able  to  disinfect  infected  wounds 
in  the  true  sense  of  the  word;  hence,  being  un- 
able to  kill  the  enemy  directly,  there  must  be 
employed  combined  measures  of  attack.  If  the 
enemy  cannot  be  combated  successfully  by 
storm,  he  must  be  starved  out.  The  first  thing 
to  be  done  is  to  cut  off  supplies — in  other  words, 
to  destroy  the  soil  that  nourishes  the  microbes, 


INFECTED    WOUNDS.  1/3 

or  to  employ  such  means  as  are  apt  to  prevent 
their  development  and  multiplication.  If  infec- 
tion of  wounds  has  taken  place,  it  is  important  to 
recognize  this  infection  as  soon  as  possible,  so  that 
further  spreading  of  the  infectious  elements  may 
be  checked  and  general  infection  be  prevented. 

Clinically,  infection  is  manifested  by  the  various 
forms  of  inflammation  and  suppuration.  They 
may  consist  of  a  common  superficial  suppura- 
tion limited  to  the  wound,  or  of  an  inflammatory 
process  surrounding  it,  and  they  are  commonly 
called  "cellulitis"  or  "phlegmon"  (from  ^Tieyiiov^, 
inflammation).  Cellulitis  may  lead  to  a  circum- 
scribed suppurative  process  called  "abscess,"  or 
to  diffuse,  often  rapidly  progressing,  inflamma- 
tory and  suppurative  processes.  The  worst  form 
of  this  progressive  inflammation  and  suppuration 
is  the  septic  phlegmon,  which  is  a  diffuse  puru- 
lent cellulitis. 

The  propagating  inflammation  of  the  skin  and 
the  subcellular  tissue  called  "erysipelas,"  which 
only  a  few  years  ago  was  still  very  frequently 
observed,  consists  in  an  inflammation  of  the  lym- 
phatic vessels  and  is  caused  by  the  streptococcus 
erysipelatis  (see  p.  38). 

The  most  fatal  poisoning  of  the  whole  system 
following  infection  of  a  wound  is  sepsis  (septi- 
caemia, septaemia).  A  very  similar  intoxication 
produces  the  symptoms  of  pyaemia  (pyohaemia — 


174  SURGICAL    ASEPSIS. 

Ttvov,  pus,  and  alixay  blood),  whose  characteristic 
difference  from  sepsis  consists  in  the  formation 
of  metastatic  abscesses  in  various  organs  of  the 
body.  This  metastatic  suppuration  is  accompa- 
nied by  the  intermittent  type  of  fever  in  pyaemia. 
A  distinct  differentiation,  however,  cannot  be 
made  between  sepsis  and  pyaemia,  as  both  con- 
ditions may  often  be  combined,  and  they  may 
frequently  produce  the  same  pathological  and 
anatomical  as  well  as  clinical  symptoms.  The 
question  arises  whether  all  such  infections  should 
be  treated  on  the  same  principles.  As  demon- 
strated in  Sections  I.  and  III.,  there  may  be  pres- 
ent in  infected  wounds,  besides  the  ordinary  pus 
microbes,  other  micro-organisms  whose  character- 
istics are  yet  unknown. 

There  must  necessarily  be  a  difference  between 
a  simple  abscess  containing  so-called  pus  bonum 
ac  laudabile  (if  this  antiquated  term  may  be 
allowed)  and  a  putrid  decomposition.  The  dif- 
ferent conditions  therein  certainly  require  some- 
what different  treatment. 

With  a  view  to  arriving  at  a  guide,  inoculations 
were  made  of  a  series  of  isolated  and  cultivated 
pathogenic  microbes  from  putrid  fluids.  The 
inoculations  always  resulted  in  a  reproduction  of 
the  same  kind  of  septicaemia.  It  must  be  borne  in 
mind,  however,  that  such  microbes,  despite  their 
being  taken  from  putrid  liquids,  need  not  neces- 


INFECTED    WOUNDS.  1 75 

sarily  produce  putrefaction,  nor  can  they  be  trans- 
ferred to  every  species  of  animal.  There  are 
certain  species  of  animals  which  possess  well- 
marked  immunity  to  certain  microbes,  and  there 
are  other  species  which  always  show  a  decided 
reaction  after  being  inoculated  with  specific  kinds 
of  microbes.  This  shows  that  there  are  various 
forms  of  animal  septicaemia.  For  instance,  the 
bacillus  of  sepsis  in  mice  (PL  III.,  Figs.  5  and  6) 
produces  no  symptoms  in  rabbits  (Section  I.,  p. 
21).  Furthermore,  it  shows  that  sepsis  in  human 
beings  is  not  identical  with  the  sepsis  of  certain 
animals.  The  microbes  which  cause  wound- 
inflammation  in  cows,  horses,  and  other  animals 
differ  entirely,  according,  to  the  observation  of 
veterinary  surgeons,  from  those  which  cause 
inflammation  in  human  beings,  and  seem  to  vary 
in  their  peculiarities  according  to  the  various 
species  of  animals,  so  that  these  experiments  can 
be  utilized  for  human  beings  only  in  a  restricted 
way.  It  is  true  that  staphylococci  and  strepto- 
cocci taken  from  cellulitic  processes  in  human 
beings  can  be  transferred  to  guinea-pigs,  mice, 
and  rabbits,  and  cause  the  same  pathological 
changes  in  these  animals;  but  most  other  mi- 
crobes cause  either  entirely  different  reactions  or 
none  at  all ;  so  that  by  these  interesting  experi- 
ments it  could  not,  in  fact,  be  proved  whether  the 
series  of  clinical  symptoms  comprised  under  the 


1/6  SURGICAL   ASEPSIS. 

denomination  ''sepsis"  are  or  are  not  due  to  one 
single  agent.      (Compare  Section  I.,  p.  51.) 

It  may  be  that  various  forms  of  sepsis  exist, 
whose  differentiation  cannot  yet  be  made  because 
of  the  still  defective  means  of  diagnosis.  Some 
microbes  can  be  recognized  by  the  microscope 
(see  p.  88),  and  thus  a  determination  as  to  the 
particular  means  of  disinfection  to  be  selected  is 
easily  made.  The  great  majority  of  microbes  at 
present  known,  however,  can  be  made  out  only 
by  bacteriological  examination  ;  this  has  the  dis- 
advantage that  the  cultivation  of  most  species  con- 
sumes such  a  long  time  as  often  to  be  practically 
useless.  It  is  superfluous  to  urge  the  importance 
of  such  examinations  in  reference  to  prognosis. 

Pasteur  has  shown,  however,  as  explained  in 
Section  I.  (p.  27),  that  one  must  distinguish 
between  aerobic  and  anaerobic  bacteria,  the  first 
developing  best  in  oxygen,  the  latter  being 
unable  to  exist  in  it.  In  wound-cavities  or  in 
effusions  following  inflammatory  processes,  as 
well  as  in  suppurative  processes — as  those  in 
the  gall-bladder,  for  instance — no  oxygen  can 
be  discovered ;  therefore  those  microbes  which 
produce  these  conditions  must  be  anaerobic — 
that  is,  they  must  be  able  to  develop  and  to  mul- 
tiply without  oxygen.  If  sncJi  is  really  the  case, 
then  the  juicrobes  would  necessarily  die  as  soon  as 
exposed  to  the  atmosphere. 


INFECTED    WOUNDS.  1 77 

Lonor  before  it  was  known  that  anaerobic  mi- 
crobes  are  destroyed  by  exposure  to  oxygen, 
surgeons,  guided  by  nothing  save  practical  ex- 
perience, knew  that  if  free  access  of  air  to  a 
cavity  was  procured — that  is,  if  a  broad  opening 
was  made — further  injury  to  the  infected  tissues 
could  often  be  prevented.  In  fact,  while  the 
brilliancy  of  that  part  of  modern  surgery  which 
is  mainly  based  upon  prophylaxis  has  passed  far 
beyond  the  surgery  of  the  past,  the  results  in 
the  treatment  of  infected  wounds  leave  much  to 
be  desired. 

Long  before  antisepsis  and  asepsis  were 
dreamed  of,  it  was  emphasized  that  free  access 
must  be  furnished  infected  wounds  by  incision  and 
drainage.  Surgeons  are  unable  to  do  much  more 
to-day.  It  may  safely  be  maintained  that  the  great- 
est step  in  this  small  progress  in  methods  of  treat- 
ing infected  wounds  dates  only  from  the  first 
methodical  packing  with  iodoform  gauze.  Brush 
and  sterilizer  alone,  valuable  as  they  are,  do  not 
complete  the  arniamentarmvi  chiriirgiann  in  this 
battle  against  conditions  practically  inestimable 
in  their  consequences.  At  this  point  some  other 
factors  of  surgical  technique  must  be  taken 
into  consideration.  A.  Jacobi,  in  his  admirable 
address^  delivered  before  the  Eleventh  Inter- 
national Medical  Congress,  asks  :   "  Is  it  enough 

^"Non  Nocere,"  Medical  Record,  May  19,  1S94. 


12 


IjS  Si'RGICAL   ASEPSIS. 

to  know  that  clean  finger-nails,  and  nurses  con- 
versant with  corrosive  sublimate,  and  disinfected 
cato^ut,  are  almost  universal  safeo^uards  ao^ainst 
immediate  fatal  termination?"  Certainly  not; 
there  is  requisite  a  series  of  procedures  the  mas- 
tering of  which  presupposes  a  perfect  knowledge 
of  a  whole  science ;  and  even  this  is  very  defective. 

If,  notwithstanding  all  aseptic  precautions  be- 
fore operation,  through  omission  of  such  safe- 
guards as  alluded  to,  through  oversight,  or 
through  any  unfortunate  accident,  infection  has 
taken  place,  an  early  recognition  of  the  symp- 
toms is  of  the  greatest  importance,  so  that  the 
necessary  steps  may  be  taken  to  arrest  the 
process  before  it  spreads  and  general  infection 
occurs. 

The  symptoms  of  infection  are  both  general  and 
local.  In  the  great  majority  of  cases  infection 
can  be  recognized  by  the  manifestation  of  general 
symptoms,  the  most  important  of  which  is  fever. 
As  shown  in  the  preceding  section  (p.  170),  the 
main  difference  between  infectious  and  aseptic 
fever  is,  on  the  one  hand,  that  the  symptoms  of 
the  latter  fever  begin  immediately  after  operation  ; 
furthermore,  that  the  temperature  generally  does 
not  exceed  102^°  F.,  and  soon  returns  to  nor- 
mal ;  on  the  other  hand,  it  is  characteristic  of  in- 
fectious fever  that  it  does  not  begin  before  twenty- 
four    hours  after  the  operation,   and  that  at  its 


INFECTED    WOUNDS.  1 79 

onset  the  temperature  rises  to  104°  F.  or  even 
higher.  The  symptoms  of  infectious  fever  gen- 
erally start  with  a  chill,  but  the  pulse  usually  in- 
dicates infection  before  the  other  symptoms  be- 
come manifest.  A  pulse-rate  of  i  20  or  more  per 
minute  is  a  very  suspicious  symptom,  and,  whether 
associated  with  a  low  or  a  high  temperature,  an- 
nounces a  serious  condition. 

In  the  further  course  of  the  most  deleterious 
septic  processes  a  normal  temperature  is  often 
found.  This  normal  condition  may  more  readily 
deceive  the  inexperienced  surgeon  as  patients 
affected  with  this  particular  form  of  sepsis  gen- 
erally feel  well  notwithstanding  the  hopelessness 
of  their  condition.  In  septic  conditions,  at  their 
onset  a  superficial  observer  may  overlook  the 
rise  of  temperature,  and  as  a  few  hours  later  the 
temperature  may  have  fallen,  the  rise  may  have 
escaped  notice  entirely.  If  the  patient  reports 
no  real  chill,  but  only  slight  shivering,  such  as 
sometimes  occurs  at  the  beginning  of  septic 
fever,  this  error  is  much  more  easily  made. 

At  the  beginning  of  the  fever  the  general  con- 
dition of  the  patient  is  usually  also  impaired, 
weakness,  anxiety,  and  sleeplessness  predominat- 
ing. Profuse  perspiration  is  very  often  present. 
The  tongue  may  be  clean,  but  it  is  always  dry. 
It  is  perhaps  superfluous  to  state  that  these  symp- 
toms imperatively  demand  immediate  inspection 


I  So  SURGICAL   ASEPSIS. 

of  the  wound.  Even  if  only  one  of  these  symp- 
toms be  present,  the  dressing  should  be  changed; 
in  case  of  doubt  it  is  preferable  to  make  this 
change  unnecessarily  rather  than  to  risk  the  con- 
sequences of  its  omission. 

In  accordance  \vith  the  general  symptonis,  the 
edges  of  the  luoiuid  usually  appear  inflamed  and 
the  skin  is  reddened  and  tender.  At  an  early  stage 
of  the  fever  pain  is  seldom  absent.  The  degree 
of  infection  and  the  extension  of  the  local  inflam- 
matory process  differ  materially.  They  fluctuate 
between  slight  lymphangitis  and  fatal  acute  pu- 
rulent oedema.  A  surgeon  may  incur  a  slight 
infection  of  the  index  finger  while  operating 
upon  a  putrid  abscess.  A  small  cut  or  a  super- 
ficial and  unnoticed  abrasion  of  the  skin  on  his 
finger  may  represent  the  avenue  of  entrance  of 
the  infection.  A  chill  may  follow  twenty-four 
hours  later,  and  his  temperature  may  rise  to 
104°  F.  The  small  sore  on  his  finger  may  be- 
come inflamed  and  may  be  the  seat  of  throbbing 
pain.  The  cubital  as  well  as  the  axillary  glands 
may  swell,  and  on  the  skin  of  the  arm  red  stripes, 
the  evidence  of  lymphangitis,  may  appear.  The 
following  day  the  whole  infectious  process  may 
have  terminated,  or  it  may  be  that  the  process  was 
localized  or  limited  by  the  production  of  circum- 
scribed abscesses  either  at  the  initial  lesion  or  in 
the  glands.     It  may  also  happen  that  general  in- 


INFECTED    WOUXDS.  l8l 

fection  takes  place,  the  process  ending  only  with 
the  death  of  the  siiroreon. 

It  would  exceed  the  boundaries  of  this  volume 
to  enter  into  further  details  of  the  pathological 
significance  of  these  various  infectious  processes, 
but  observation  teaches  that  at  present  diagnos- 
tic means  are  not  sufficiently  advanced  to  enable 
one  always  with  certainty  at  an  early  stage  to 
distinguish  between  an  innocent  and  a  fatal  cha- 
racter of  infection,  except  under  the  conditions 
alluded  to  on  page  88.  Therefore,  in  brief,  all 
kinds  of  infectious  symptoms  must  be  deemed 
serious.  Even  the  most  innocent-looking  suppu- 
ration of  a  stitch-canal  may,  through  the  accu- 
mulation of  unfortunate  circumstances,  be  the 
beginning  of  a  grave  course. 

Suppuration  of  stitch-canals  develops  from  the 
canals  of  the  sutures,  and  is  generally  caused  by 
catgut  or  silk  which  either  was  not  thoroughly 
sterilized  or  which  became  infected  during  opera- 
tion. The  danger  of  suppuration  will  be  en- 
hanced by  the  presence  of  considerable  tension 
where  there  is  a  tendency  of  the  wound-edges  to 
gape.  Suppuration  of  stitch-canals  may  be  super- 
ficial as  well  as  deep-seated  ;  the  latter  especially 
may  be  expected  in  buried  sutures.  When  sup- 
puration is  only  superficial,  the  symptoms,  nat- 
urally, are  not  so  intense  as  when  it  is  deep- 
seated,  for  the  first  condition  is  readily  followed 


1 82  SURGICAL   ASEPSIS. 

by  early  and  spontaneous  discharge  of  pus 
through  the  integument.  As  a  consequence  the 
general  condition  of  the  patient  may  be  disturbed 
so  little  that  suppuration  is  not  noticed  before 
the  dressing  is  changed,  when  attention  will  be 
called  to  it  by  the  escape  of  a  drop  of  pus  from 
a  stitch-canal. 

Pus  very  often  appears  only  after  the  suture 
has  been  removed.  In  case  of  pus-7^etention 
there  will  be  observed  redness,  infiltration  of 
the  wound  and  the  adjacent  parts,  and  pain  on 
pressure.  It  is  evident  that  sutures  must  be 
removed  without  delay  when  their  canals  sup- 
purate; this  removal  alone  sometimes  suffices 
to  prevent  further  suppuration.  If  retention  Is 
discovered,  incisions  should  be  made  to  liberate 
the  pus. 

Sometimes  blisters  filled  with  a  sero-purulent 
fluid  are  present.  In  this  case  the  epidermis 
must  be  removed.  This  is  done  best  with  scis- 
sors curved  on  the  flat. 

If  suppuration  follows  the  application  o{  buned 
sittureSy  local  as  well  as  general  symptoms  are  of 
much  greater  intensity.  In  the  majority  of  cases 
the  patient  shows  a  high  temperature  (at  least 
103°  F.),  the  pain  becomes  intolerable,  and  the 
patient  complains  of  a  pulsating  sensation  in 
the  wound.  There  are  also  present  headache, 
loss  of  appetite,  and  other  general   symptoms. 


INFECTED    WOUNDS.  1 83 

In  such  cases  after  the  dressing  is  removed  there 
will  be  noticed  intense  redness  and  a  painful  in- 
filtration of  the  tissues.  Collateral  oedema  will 
seldom  be  absent.  A  fluctuating  point  may  now 
be  discerned,  or  a  part  of  the  pus  may  be  dls- 
charofinof  through  one  or  another  of  the  stitch- 
canals. 

If  an  abscess  has  formed  between  two  stitch- 
canals,  it  generally  suffices  to  introduce  a  Pean 
forceps  through  the  line  of  incision  and  to  separ- 
ate the  edges  of  the  wound  by  opening  the  blades 
of  the  forceps.  If  the  pus  cannot  be  evacuated 
in  this  way,  incisions  are  in  order ;  they  should 
be  made  rather  too  long  than  too  short,  so  as 
to  relieve  tension  while  permitting  the  discharge 
of  the  pus. 

\{  supei^ficial gang7^ene  of  the  lips  of  the  wound 
occurs,  their  immediate  removal  with  forceps  and 
scissors  is  indicated,  for  gangrene  will  present  a 
most  favorable  soil  for  the  development  of  mi- 
crobes, at  the  same  time  causing  retention  of  pus. 
Whenever  symptoms  of  infiltration  and  swelling 
are  found,  even  before  any  evidence  is  presented 
of  the  presence  of  pus,  an  incision  should  be 
made.  (See  Section  XIL,  on  Renewal  of  Dress- 
ings, p.  230.)  By  making  incisions  thus  early  it 
is  often  possible  to  prevent  necrosis  in  fasciae,  in 
the  sheaths  of  tendons,  or  In  bones. 

In    extensive    phlegmonous    processes    a    very 


1 84  Si'RGICAL   ASEPSIS. 

thorough  examniation  of  the  adjoining  and 
apparently  healthy  parts  must  be  made,  as  they 
sometimes  retain  pus.  The  graver  the  general 
symptoms,  the  more  extensive  should  be  the 
incisions.  The  incisions  should  expose  the  area 
of  the  suppurating  process  as  extensively  as  pos- 
'  sible,  and  all  edges  and  pockets  should  be  laid 
open.  In  deep-seated  phlegmons  an  incision 
throuo^h  the  skin  and  fascia  must  first  be  made, 
and  a  passage  be  established  with  a  grooved 
director  or  a  small  Pean  forceps.  If  the  focus  is 
found,  the  passage  may  be  dilated  with  the  for- 
ceps. The  next  procedure  is  to  keep  the  abscess- 
cavity  open  by  drainage,  which  can  best  be 
accomplished  by  employing  absorbent  gauze. 
Rubber  tubes  will  only  exceptionally  be  required. 

These  procedures,  especially  the  evacuation  of 
pus  and  the  thorough  removal  of  mortifying  tissue, 
are  apt  to  destroy  the  soil  which  favors  the  develop- 
ment and  multiplication  of  microbes,  and  they  are 
therefore  of  far  greater  importance  than  the  use 
of  any  or  all  of  the  so-called  ''antiseptic  solutions'' 
In  fact,  these  procedures  deserve  much  more  the 
name  of  disinfectants. 

Schimmelbusch^  claimed  that  no  infected  wound 
can  be  disinfected  even  though  an  antiseptic  fluid 
be  applied  immediately  after  infection.     Not  only 

*  Transactions  of  the  XXII.  and  XXIII.  Surgical  Congresses,  Berlin, 
April  15,  1S93,  and  April  18,  1894. 


INFECTED    WOUNDS.  1 85 

bichloride,  carbolic  acid,  lysol,  acetate  of  alumi- 
num, chloride  of  zinc,  etc.,  but  also  caustics  like 
nitric  and  acetic  acid,  were  used  without  the 
slio-htest  effect.  Thi?  result  shows  that  the 
micro-organisms  permeate  the  tissues  very  rap- 
idly, and  as  speedily  get  beyond  the  reach  of 
antiseptic  liquids.  Five  minutes  after  the  intro- 
duction of  pathogenic  as  well  as  non-pathogenic 
microbes  into  fresh  wounds,  the  internal  viscera 
contained  them.  Fortunately,  as  especially  shown 
in  Section  III.,  these  conditions  do  not  corre- 
spond entirely  with  those  represented  in  surgical 
practice,  as  the  patients  ordinarily  are  not  inocu- 
lated with  pure  cultures  of  highly  virulent  micro- 
organisms. Clinical  experience  has  shown  that 
much  can  be  done  in  infected  wounds  by  follow- 
ing the  principles  of  open-wound  treatment  (see 
Section  XL). 

Henle^  claims  that  he  was  able  to  disinfect 
wounds  inflicted  upon  rabbits'  ears  by  strepto- 
cocci with  solutions  of  bichloride  (i  :  looo)  and 
of  carbolic  acid  (4  :  100)  two  hours  after  inocu- 
lation ;  six  hours  afterward  he  was  unable  to  do 
so,  but  the  severity  of  the  infection  was  con- 
siderably diminished. 

^  Deutsche  Gesellschaft  fiir  Chirtirgie,  XXIII.  Congress,  Berlin,  April, 
1894. 


l86  SURGICAL    ASEPSIS. 

XL  ASEPTIC   OPEN-WOUND   TREATMENT. 

As  shown  in  the  preceding  section,  infected 
or  suppurating  wounds  should,  as  a  rule,  be 
kept  open.  The  same  plan  should  be  followed 
in  all  wounds  other  than  those  inflicted  by  the 
surgeon,  as  such  wounds  must  practically  be 
regarded  as  contaminated. 

A  commonly-adopted  surgical  principle  de- 
mands coaptation  of  divided  surfaces  by  sutures. 
Whenever  it  can  be  determined  that  no  con- 
tamination of  the  wound  has  taken  place,  such 
coaptation  will  be  wise ;  but  this  can  never  be 
proved  in  accidental  injuries,  hence  there  is 
always  a  risk  in  uniting  such  wounds.  Were 
one  really  able  to  do  what  all  text-books  advise 
and  what  most  regard  as  an  undeniable  possi- 
bility— namely,  the  thorough  disinfection  of  a 
contaminated  wound  by  simply  washing  it  with 
so-called  disinfectants — the  omission  of  the  suture 
would  be  inexcusable.  But  the  only  fresh  wounds 
that  are  really  aseptic,  in  the  trite  se^ise  of  the 
word,  are  those  made  in  healthy  tissues  by  aseptic 
instruments  in  the  aseptic  hands  of  a  surgeon. 

An  accidental  wound  perchance  may  be  aseptic, 
but  it  necessarily  must  have  been  inflicted  on  a 
clean  person  by  a  clean  instrument,  and  little  time 
must  have  elapsed  before  it  came  under  the 
observation  of  the  surgeon.     The  chances  may 


SURGICAL     ASEPSIS. 


Plate  VI. 


s    . 

<     ^ 


>      O 


ASEPTIC  OPEN-WOUND    TREATMENT.  1 87 

then  be  that  if  the  pruiciples  detailed  in  Section 
IX.  on  Aseptic  Wounds,  are  observed,  union  by 
first  intention  may  be  obtained.  Hence  com- 
pound fractures  with  small  wounds  of  the  integ- 
ument— gunshot  wounds,  for  instance — show  a 
great  tendency  to  heal  if  they  are  treated  asep- 
tically — that  is,  if  they  are  merely  cleansed 
according  to  the  principles  of  prophylactic  disin- 
fection described  in  Section  IV. 

A  priori,  it  may  be  assumed  that  a  bullet  car- 
ries with  it  pathogenic  microbes  from  the  cloth- 
ing, etc. ;  but  clinical  experience  shows  that  infec- 
tion very  rarely  occurs  in  this  way,  provided  the 
surgeon  avoids  severe  manipulations,  such  as 
probing,  incising,  draining,  etc.,  and  simply  fol- 
lows the  principles  of  prophylactic  disinfection. 
It  may  be  that  to  some  extent  the  heat  of  the 
bullet  has  something  to  do  with  the  frequent 
aseptic  course  of  gunshot  wounds. 

During  the  Franco-German  war  (1870)  Bern- 
hard  von  Langenbeck  had  the  opportunity  of 
observing  at  one  time  eleven  cases  of  gunshot 
wounds  in  the  knee-joint.  According  to  the 
routine  of  that  time,  all  patients  were  told  that  if 
they  would  not  submit  to  amputation  they  must 
die.  Ten  consented  to  amputation,  and  died 
with  the  satisfaction  of  having  been  treated  se- 
cundum artem  ;  but  one  patient,  a  stupid  soldier 
who  preferred  death  to  amputation,  recovered. 


I  88  SURGICAL   ASEPSIS. 

Nowadays  the  real  scientific  question  to  be  de- 
termined is  whether  or  not  any  microbes  can  be 
discovered  and  cultivated,  and  if  so,  what  spe- 
cies. The  absence  of  microbes  or  the  presence 
of  innocent  ones  would  require  coaptation  of  the 
wound-edges,  while  the  presence  of  virulent 
microbes  would  demand  open-wound  treatment. 
But  this  conclusion  can  be  arrived  at  practically 
only  under  the  conditions  described  in  Section  III., 
on  the  Means  of  Disinfection  (see  p.  88),  and  so 
the  experience  and  ability  of  the  surgeon  must 
frequently  govern  the  decision  as  to  whether  a 
solution  of  continuity  shall  be  treated  as  an  open 
or  as  a  closed  wound.  A  wound  inflicted  by  a 
stone  upon  a  labor-soiled  hand  has  poor  chances 
of  union  by  first  intention,  therefore  to  seek  to 
obtain  such  union  would  be  useless. 

The  principles  governing  the  open  treatment 
of  wounds  were  followed  long  before  the  terms 
antisepsis  and  asepsis  existed.  It  was  well  known 
that  an  irreenlar  w^ound  converted  into  a  smooth- 
surface  wound  in  which  neither  retention,  decom- 
position, nor  absorption  of  the  wound-products 
is  possible  offers  better  chances  for  healing  if 
treated  by  the  open  method  than  if  it  were  oc- 
cluded. 

In  1806,  Vincenz  von  Kern,  an  eminent  Ger- 
man surgeon,  recommended  the  open  treatment 
of  wounds  {pansenient  a  del  ouvert)  as  a  method. 


ASEPTIC   OPEN-WOUND    TREATMENT.  1 89 

He  saw  that  it  was  likely  to  prevent  putrefaction 
by  keeping  the  edges  of  the  wound  well  separated, 
thus  giving  free  access  of  air  and  at  the  same 
time  permitting  escape  of  the  discharges.  His 
results  were  the  most  favorable  known  at  that 
time.  His  method  was  employed  especially  after 
amputations,  when,  hemorrhage  being  thoroughly 
stopped,  the  entirely  uncovered  stump  was  laid 
upon  a  pillow  so  that  the  discharges  could  flow 
into  a  basin  placed  beneath.  Healing  took  place 
by  suppuration  and  granulation.  The  discharges 
always  freely  escaped,  and  consequently  purulent 
absorption  could  not  take  place.  In  large  and 
complicated  cavities  this  method,  unfortunately, 
was  not  so  rigorously  carried  out,  probably  be- 
cause of  the  fear  which  prevailed  in  former  years 
of  making  large  incisions. 

An  irregular  cavity — that  is,  a  cavity  in  which 
several  wound-canals  lead  toward  various  parts 
of  the  tissues  and  end  in  small  cavities  that  pre- 
sent superficial  openings — would,  if  left  uncov- 
ered, not  answer  the  spirit  of  this  method.  True, 
the  air  would  be  able  to  enter,  but  it  would  not 
have  access  to  all  portions,  nor  could  it  circulate 
in  the  cavity.  Superficial  or  temporary  union  of 
these  deep-seated  cavities  might  even  entirely 
occlude  them  from  the  atmosphere.  They  would 
then  become  veritable  hot-beds  for  the  develop- 
ment of   micro-orofanisms    in    the    retained    dis- 


I  GO  SURGICAL    ASEPSIS. 

charges.  Such  cavities  must  be  exposed  as 
freely  as  possible,  the  pus  must  be  allowed  to 
escape,  and  the  broken-down  tissues  must  be 
removed.  The  question  then  arises  as  to  the 
best  manner  of  keeping  open  the  exposed  parts. 
Von  Mosetiof-Moorhof  devised  a  method  which 
not  only  answers  this  purpose,  but  which  at  the 
same  time  also  exerts  a  decided  and  permanent 
microbicidal  influence  upon  the  infected  tissues. 
This  method  consists  in  methodical  drainine"  or 
in  tamponing  with  iodoform  gauze,  the  prepara- 
tion of  which  has  been  described  on  page  123. 
As  shown  in  Section  III.  (p.  ^;^),  iodoform  is  not 
an  antiseptic  in  the  same  sense  as  carbolic  acid 
or  bichloride.  But  undoubtedly  iodoform  ren- 
ders the  products  of  the  microbes  in  question 
harmless  by  forming  with  them  innocuous  com- 
binations. In  organic  tissue  a  decomposition  of 
the  iodoform  takes  place,  nascent  iodine  probably 
being  set  free,  during  which  process  bactericidal 
effects  are  exerted. 

It  is  essential,  after  the  preliminary  conditions 
described  above  are  fulfilled,  that  the  gauze  be 
brought  into  contact  with  every  portion  of  the 
wound,  as  iodoform  has  no  effect  save  by  imme- 
diate contact.  The  packing  should  be  done 
as  loosely  as  possible,  except  when  pressure  is 
required  to  control  hemorrhage. 

If    rubber    drainage    is    used,    no    antiseptic 


ASEPTIC   OPEN-WOUND    TREATMENT.  I9I 

influence  will  be  exercised  upon  the  wound  or 
the  cavity  itself;  but  when  in  a  united  wound 
the  antiseptic  gauze  covers  the  outer  ends  of 
the  tubes,  it  prevents  decomposition  of  the 
wound-products  only  after  they  have  left  the 
tubes  and  have  entered  the  gauze,  so  that  the 
absorbent  qualities  of  the  gauze,  which  are  of 
great  value,  are  not  utilized.  If  a  cavity  be 
packed  thoroughly  with  gauze,  every  particle  of 
discharge  must  be  absorbed,  and,  however  large 
the  cavity,  the  pus  will  be  in  the  gauze  only,  and 
the  wound-surface  cannot  be  otherwise  than  dry. 

A  drainaofe-tube  does  not  withdraw  or  absorb 
pus,  for  it  has  no  power  to  aspirate  the  pus,  which 
merely  traverses  the  tube,  its  lumen  being  the 
point  of  least  resistance.  But  the  flow  through 
the  tube  occurs  only  when  pus  is  abundant,  which 
is  the  first  step  to  its  retention. 

If  the  cavity  be  left  open,  the  surgeon  will  be 
able  to  examine  the  field  of  operation,  which  ex- 
amination will  be  impossible  when  the  wound  is 
occluded.  Laro^e  incisions  enable  the  surgeon 
to  inspect  as  much  of  the  tissue  as  possible,  and 
it  is  almost  as  desirable  to  inspect  suspicious 
wound-surfaces  after  operation  as  it  is  to  do  so 
during  operation.  Oftentimes  tissues  which  at 
the  time  of  operation  were  supposed  to  be  of 
sufficient  vitality,  become  later  on  gangrenous  ; 
or  in  operations  on  tubercular  joints  or  glands 


192  SURGICAL   ASEPSIS. 

tubercular  tissue  has  been  overlooked  and  left  in 
sittc.  It  is  little  trouble  to  remove  such  diseased 
portions  from  an  open  wound  later  on,  while  if 
coaptation  was  the  aim  of  the  surgeon  this  valu- 
able feature  would  be  relinquished. 

Amputation  of  a  finger  may  illustrate  the  prin- 
ciples underlying  open-wound  treatment.  Let  it 
be  assumed  that  a  phalanx  of  a  machinist's  finger 
is  crushed  by  a  machine.  The  appearance  of  the 
fineer  in  this  case  will  show  considerable  chancre, 
and  the  edges  of  the  wound  will  be  irregular. 
Bloody  infiltration,  blue  or  black  discoloration, 
swelling,  and  irregular  form  of  the  finger  are 
striking  characteristics  of  the  degree  of  de- 
struction. As  the  amount  of  infiltration  of  the 
tissues  varies  according  to  the  amount  of  the 
force  to  which  they  have  been  subjected,  extrav- 
asation may  extend  far  beyond  the  wound.  The 
edges  of  the  wound  as  well  as  the  deep-seated 
tissues  may  be  so  crushed  that  perfect  necrosis 
has  taken  place.  Bleeding  may  be  stopped  by 
the  crushing,  and  sensation  in  the  part  may  be 
lost  entirely.  Fasciae,  tendons,  and  nerves  may 
be  crushed,  and  the  phalanx  may  be  reduced  to  a 
number  of  fragments.  In  this  case  conservative 
surgery  is  at  a  loss.  The  phalanx  must  be  re- 
moved, not  only  because  it  is  useless  to  the 
patient,  but  because  it  would  also  be  an  incu- 
bator for  the  development  of  microbes,  proving 


ASEPTIC  OPEN-WOUND    TREATMENT.  1 93 

of  great  danger  for  the  hand,  the  arm,  or  even 
the  Hfe  of  the  injured  man,  as  a  wound  of  this 
kind  cannot  but  be  regarded  as  infected. 

After  the  necessary  aseptic  precautions  (see 
Section  X.,  on  Infected  Wounds)  have  been 
taken,  the  fingers  and  the  hand  are  scrubbed 
thoroughly  with  a  brush  and  soap.  These  pro- 
cedures follow  the  use  of  ether  for  removing  any 
fatty  and  oily  substances  with  which  the  clothing 
of  the  patient  or  the  inflicting  instrument — for  in- 
stance, the  wheels  of  a  machine — may  have  been 
contaminated.  Then  alcohol  and  the  bichloride 
are  used,  after  the  principles  of  prophylactic  dis- 
infection (Section  IV.,  p.  95).  The  whole  arm 
must  then  be  enveloped,  and  the  entire  vicinity 
of  the  injury  be  covered,  with  sterilized  towels 
taken  directly  from  a  sterilizing  apparatus.  The 
necessary  instruments — namely,  knives,  retract- 
ors, bone-cutting  forceps,  strong  forceps  to  hold 
bone-fragments,  tenacula  and  artery  forceps,  and 
dressing  material — must  be  sterilized  in  the  man- 
ner  described  in  Section  V.  If,  as  may  happen 
in  private  practice,  a  sterilizer  is  not  available, 
the  instruments,  etc.  may  be  made  sterile  in  a 
common  boiling-pot  (see  Section  XVI.  ;  Fig.  63). 

If  the  tissues  on  both  sides  of  the  finger  are 
fit  for  use,  a  double  flap  may  be  formed.  The 
aggregate  length  of  these  flaps,  which  may  con- 
sist of  skin  only,  must  be  somewhat  more  than 

13 


194  SURGICAL   ASEPSIS. 

the  diameter  of  the  finger  at  the  level  at  which 
the  bone  is  exsected  or  disarticulated,  and  only 
when  amputation  higher  up  is  necessary  is  it 
advisable  to  leave  some  healthy  muscular  tissue 
in  connection  with  the  skin-flap. 

Such  procedures  are  very  much  facilitated  by 
the  Esmarch  method  of  constriction — that  is,  by 
firmly  applying  a  rubber  bandage  from  below 
upward,  without  reverses,  to  -just  above  the 
wrist.  The  rubber  band  is  carried  around  the 
limb  and  is  well  stretched.  After  it  is  tied  by 
its  crossied  ends  or  secured  by  its  hook  and 
chain,  the  rubber  bandaofe  which  was  carried 
around  the  limb  may  be  released.-^  After 
removing  all  tissues  whose  vitality  seems  im- 
paired, and  after  bleeding  is  carefully  arrested, 
the  flaps  are  kept  widely  separated  by  iodoform 
gauze  which  is  brought  into  close  contact  with 
each  angle  or  pocket  of  the  wound.  A  piece 
of  sterilized  moss  or  a  voluminous  mass  of  steril- 

^  Previous  to  employing  an  Esmarch  bandage  the  limb  should  be  en- 
veloped with  a  sterilized  towel  or  a  bandage,  which  may  be  cut  or  lifted 
from  the  site  of  operation  after  the  constricting  bandage  is  taken  off.  It 
being  somewhat  difificult  to  keep  rubber  bandages  sterile  without  impairing 
their  usefulness,  Neuber,  Bardeleben,  and  other  surgeons  returned  to  the 
old  method  of  Stromeyer,  who  used  only  strong  linen  bandages  moist- 
ened before  application.  There  can  be  no  doubt  tliat  the  marked  ease 
with  which  linen  bandages  can  be  made  and  kept  sterile,  as  well  as 
their  durability,  is  a  great  advantage.  Their  application,  furthermore,  is 
followed  by  far  less  parenchymatous  hemorrhage,  after  the  constriction  is 
released,  than  occurs  after  the  use  of  the  ruljber  bandage.  Their  main 
disadvantage  is  the  greater  care  with  which  they  must  be  applied. 


ASEPTIC   OPEN-WOUND    TREATMENT.  1 95 

ized  gauze  must  then  be  applied  over  the  stump 
to  absorb  the  sanguineo-serous  discharge  of  the 
wound-surfaces. 

A  spHnt  of  some  kind  should  always  be  em- 
ployed. A  long  piece  of  moss-board  merely 
dipped  into,  and  not  soaked  in,  sterilized  water 
answers  the  purpose  admirably,  for  if  the  dis- 
charges become  abundant  they  will  readily  be 
absorbed  by  the  moss  splint  without  impairing 
its  value  as  an  immobilizing  apparatus.  The 
dressing  should  reach  to  the  elbow. 

If  the  patient's  condition  remains  normal  and 
if  no  local  symptoms  supervene  within  forty- 
eight  hours,  the  wound  may  be  deemed  in 
an  aseptic  state.  The  dressing  must  then  be 
changed  and  the  packing  be  withdrawn.  If  the 
surfaces  appear  clean  and  healthy,  the  flaps 
may  be  approximated  accurately  and  be  kept 
adjusted  by  carrying  long  strips  of  iodoform 
gauze  around  them.  If  coaptation  is  thus  not 
sufficiently  thorough  to  make  the  surfaces  ad- 
here, the  discharges  may  continue  and  imperfect 
union  may  result.  But  even  in  such  a  case 
retention  can  hardly  take  place,  as  the  amount 
of  pressure  exerted  by  the  surrounding  gauze 
is  so  slight  that  the  discharge  easily  finds  its  way 
out  into  the  gauze.  If  there  should,  however, 
be  any  fear  of  retention,  a  small  strip  of  gauze 
may  be  inserted  into  one  angle  of  the  wound. 


196  SURGICAL   ASEPSIS. 

In  the  great  majority  of  cases  union  by  first 
intention  is  still  obtained  in  this  way,  and  it 
should  certainly  be  striven  for  if,  on  the  change 
of  the  first  dressing,  an  examination  of  the 
wound-surfaces  shows  healthy  granulations.  It 
is  generally  unnecessary  to  apply  secondary  su- 
tures in  such  cases.  In  wounds  occluded  imme- 
diately after  operation,  when  they  have  become 
infected  or  distended  by  blood-clots  reopening 
is  imperative  (see  Section  XII.,  on  Renewal  of 
Dressings) ;  primary  union,  on  the  contrary,  may 
still  be  secured,  even  if  sutures  are  applied  so 
late  as  three  days  after  operation,  provided  the 
wound  is  then  in  an  aseptic  state. 

A  patient  suffering  from  an  injury  such  as 
described  might  have  recovered  a  few  days  ear- 
lier if  sutures  had  been  applied  to  his  finger 
at  the  time  of  the  operation  ;  but  it  cannot  be 
denied  that  the  risk  of  further  infection  is  con- 
siderably lessened  by  the  above-described  open- 
wound  treatment.  The  delay  is  decidedly  pref- 
erable to  the  risk  of  infection  on  account  of  too 
thorough  occlusion.  The  absorption  of  septic 
material  will  then  not  be  arrested  by  reopening 
the  wound,  nor  will  a  fatal  course  be  stayed. 

Where  cosmetic  points  come  into  question — 
in  wounds  upon  the  face,  for  instance — the  prin- 
ciples of  first  and  of  secondary  union  may  some- 
times be  combined.     The  wound  may  be  united 


ASEPTIC   OPEN-WOUND    TREATMENT.  1 97 

partially,  especially  where  the  edges  are  easily 
approximated,  and  at  different  points  between 
the  stitches  iodoform  wicks  may  be  introduced 
and  be  allowed  to  remain  for  two  or  three  days, 
or  until  there  is  no  doubt  as  to  the  aseptic  state 
of  the  wound. 

If  the  wound-surfaces  do  not  show  healthy 
granulations — that  is,  if  there  are  symptoms  of 
infection — and  if  at  the  same  time  the  general 
condition  of  the  patient  is  impaired,  the  packing 
must  be  continued.  The  views  on  obligate  and 
facultative  anaerobes  discussed  in  Section  I.  now 
find  their  practical  application  in  our  allowing 
free  access  of  air — that  is,  of  oxygen — to  the 
wound. 

Knowledge  of  the  biological  peculiarities  of 
pathogenic  bacteria  facilitates  their  destruction, 
or  at  all  events  aids  in  the  prevention  of  their 
further  multiplication.  The  more  dangerous  is 
the  quality  of  the  infectious  element — that  is,  the 
more  grave  is  putrefaction — the  more  strictly  do 
the  laws  of  anaerobiosis  apply.  The  access  of 
oxygen  alone  can  do  much  more  to  destroy  bac- 
teria than  can  oceans  of  bichloride. 

In  putrid  wounds  no  efforts  at  drying  dis- 
charges should  be  made.  The  absorption  of  the 
discharges  would  be  a  grave  error,  inasmuch  as 
they  originate  from  a  decomposed  septic  focus, 
and  undoubtedly  would  become  stagnant  beneath 


198  SURGICAL   ASEPSIS. 

the  dry  dressing.  In  this  position  the  discharges 
would  prove  merely  a  protection  for  the  microbes, 
which  would  then  be  surrounded  by  their  prod- 
ucts, the  toxines.  These  toxines  would  form 
a  kind  of  bulwark  for  the  microbes,  thus  ren- 
dering them  so  much  more  resistant  to  disin- 
fecting  procedures. 

Free  access  of  air  is  best  obtained  by  exten- 
sive incisions  (even  if  they  are  only  of  an  explor- 
atory character)  into  suspicious  tissue  and  by 
radical  and  repeated  excision  of  apparently 
necrotic  portions.  In  such  cases  it  is  justi- 
fiable even  to  remove  tissue  not  completely 
necrosed ;  but  when  the  appearance  of  the  tis- 
sues (especially  their  discoloration,  loss  of  firm- 
ness, etc.)  manifests  considerable  impairment  of 
vitality — as,  for  instance,  in  burns  of  the  third 
degree — they  must  be  removed  without  delay. 
Loose  packing  with  gauze  (preferably  iodoform 
gauze),  especially  if  the  gauze  is  not  fastened 
by  a  roller  bandage,  but  remains  in  the  wound- 
cavity  uncompressed,  does  not  interfere  with  cir- 
culation of  the  air  in  the  exposed  interstices. 

As  clinical  experience  shows,  moisture,  while 
it  should  ordinarily  be  avoided  in  the  treatment 
of  wounds,  is  well  borne  in  putrid  zvound-cavities. 
Moisture  can  be  applied  by  soaking  the  gauze 
introduced  into  the  cavities  with  a  weak  solution 
of   bichloride    every   hour;    a    i  :  5000    solution 


ASEPTIC   OPEN-WOUND    TREATMENT.  199 

generally  proves  strong  enough  for  this  purpose. 
If  packing  has  been  done,  however,  antiseptics 
must  be  applied  to  a  cavity  in  a  liquid  form,  to 
enable  them,  by  permeating  the  gauze,  to  come 
into  direct  contact  with  the  wound-surfaces  and 
to  exercise  a  permanent  influence  upon  them. 
Sterile  gauze  can  be  used  for  this  purpose  as 
well  as  iodoform  gauze,  the  latter  being  pre- 
ferred by  the  writer,  as  the  influence  of  Iodoform 
is  not  impaired  by  its  contact  with  the  bichloride 
solution.  While  in  aseptic  wounds  the  dressing 
should  be  left  undisturbed  as  long  as  possible,  in 
infected  wounds  its  renewal  even  two  or  three 
times  a  day  would  not  be  excessive. 

In  surfaces  of  great  extent,  as  in  burns  of  the 
second  and  third  degrees,  weak  antiseptics  (sali- 
cylic or  boric  acid  or  acetate  of  aluminum)  may  be 
used.  The  least  poisonous  of  these  drugs  is  the 
acetate  of  aluminum:  i  to  2  per  cent,  of  the  drug 
in  boiled  water  generally  answers  the  purpose  (see 
p.  81).  These  drugs  are  partially  absorbed  by  the 
skin,  and,  although  they  cannot  really  disinfect  an 
infected  wound  directly,  yet  in  the  course  of  time 
they  exercise  an  indirect  influence  by  diminishing 
the  multiplication  of  the  microbes.  If  bichloride 
be  preferred,  a  strength  of  i  :  1000  (later  on, 
when  healthy  granulations  appear,  i  :  2000  or 
I  :  5000)  will  serve  this  purpose;  but  such  disin- 
fecting influence  is  possible  only  when  the  main 


2C0 


SURGICAL   ASEPSIS. 


requirements — namely,    free    incisions    and    free 
access  of  air — are  fulfilled. 

IniniobiUzation  is  a  strong  adjunct  in  the  treat- 
ment of  all  kinds  of  wounds.  Therefore,  if,  as 
alluded  to  in  the  case  of  the  infected  fineer, 
the  primary  focus  as  well  as  its  suspicious  vicin- 
ity be  exposed  freely  and  loose  packing  be  done, 
a  splint  reaching  as  far  as  the  elbow  should  be 
adjusted,  preferably  at  the  side  on  which  no 
incisions  have  been  made.  The  most  desirable 
support  of  this  kind  is  a  wire  splint  (Fig.  52),  such 
as  Kramer's,  or  the  writer's  modification  of  it. 


i 

■ 

■ 

: 

= 

= 

= 

- 

•- 

Fig.  52. — Simple  wire  splint. 

If  this  splint,  after  being  boiled  and  loosely 
covered  with  sterilized  gauze,  is  so  adjusted 
by  a  gauze  bandage  that  it  encircles  the  ex- 
tremity without  covering  the  wound-surfaces,  it 
neither  interferes  with  the  principles  of  open- 
wound  treatment  nor  impedes  the  action  of  anti- 
septic fomentation.  The  writer  may  venture  to 
say  that  his  modification  of  the  Kramer  wire 
splint  allows  much  easier  adaptation  to  the 
curves  of  the  body  than  the  original  Kramer 
splint,  consequently  it  can  more  advantageously 
be  used  to  immobilize  regions  of  irregular  con- 


ASEPTIC   OPEN-WOUND    TREATMENT.  20I 

tour,  such  as  the  neck  after  an  operation  upon 
the  cervical  vertebrae.  The  treatment  described 
above  will  often  be  followed  by  the  conversion 
of  putrid  discharges — discolored,  muddy,  and  of 
an  offensive  odor — into  yellow,  inodorous  pus. 

After  the  mortified  tissues,  as  well  as  those 
that  have  been  injured  seriously,  are  removed, 
there  takes  place  a  copious  accumulation  of 
migratory  cells  and  a  rapid  multiplication  of  the 
fixed  cells,  in  consequence  of  which  there  forms 
granulation-tissue  containing  cells  and  vessels  in 
abundance.  The  surface  of  this  kind  of  tissue 
is  liquefied  into  so-called  pics  bonum  ac  laudabile. 
If  removal  of  dead  tissue  be  not  accomplished 
by  the  surgeon,  this  process  of  liquefaction  will 
separate  the  healthy  from  the  necrosed  tissue. 

The  richer  the  vascularity  the  more  rapid  is 
the  process  of  separation.  (The  spontaneous 
separation  of  dead  fragments  of  fasciae,  tendons, 
and  bones  would  require  considerable  time.) 
As  soon  as  the  wound- surfaces  are  free  of  dead 
tissue,  when  the  granulations  are  normal  and 
the  local  symptoms  as  well  as  the  general  con- 
dition of  the  patient  are  satisfactory,  the  wound 
may  again  be  treated  on  the  previously  described 
dry  principles — that  is,  by  packing  it  with  iodo- 
form gauze  and  protecting  it  with  a  sterilized 
moss  splint.  This  dressing  usually  does  not 
require   to  be  changed  oftener  than  every  sec- 


202  SURGICAL   ASEPSIS. 

ond  or  third  day.  By  following  the  principles  of 
open-wound  treatment  even  malignant  oedema, 
the  bacillus  of  which  is  most  virulent  and  very 
resistant,  may  be  treated  successfully. 

A  short  time  ao^o  the  writer  discharged  from 
the  surgical  department  of  St.  Mark's  Hospital  a 
patient  who  entered  the  institution  seven  weeks 
previously  with  the  most  alarming  symptoms. 
The  history  of  this  man,  aged  thirty-five  years, 
revealed  that  internal  urethrotomy  had  been  per- 
formed by  an  able  surgeon  who  found  the  patient 
with  an  impermeable  stricture.  The  operation 
was  rapidly  followed  by  the  most  intense  reac- 
tion. The  penis  and  the  scrotum  swelled  to  an 
enormous  size  within  twenty-four  hours,  the  pre- 
puce and  a  considerable  portion  of  the  pars 
pendula  being  black  and  blue  ;  the  neighboring 
tissues  emitted  a  fine  crepitus  when  pressed  by 
the  finger,  and  the  overlying  cutis  was  raised 
into  blebs  filled  with  red  and  yellow  serum. 

The  patient  presented  a  typical  picture  of  great 
prostration  and  profound  septicaemia.  His  almost 
constant  apathy  was  interrupted  by  occasional 
delirious  attacks.  The  pulse-rate  was  146  and 
the  temperature  was  102.5°  F.  The  tongue  was 
dry.  The  emphysematous  oedema  and  the  ensu- 
ing gangrene  naturally  pointed  to  grave  infection, 
to  combat  which  required  immediate  and  heroic 
means.     In  consideration  of  the  very  weak  pulse 


ASEPTIC   OPE h'- WOUND    TREATMENT.  2C3 

and  of  the  apathetic  condition  of  the  patient  no 
anaesthetic  was  given.  Deep  incisions  were  made, 
reachlnor  from  the  anus  across  the  scrotum,  alonor- 
side  the  penis,  and  up  to  the  left  lumbar  region. 
Within  the  extent  of  this  whole  area  the  cuticle 
was  raised  into  blebs  filled  with  sano^uinolent 
serum.  The  incised  tissues  were  partially  livid, 
partially  gray  and  bluish-black,  and  were  infil- 
trated with  foul-smellinor,  acrid  secretions  and 
with  the  gaseous  products  of  decomposition. 
Everywhere  underneath  the  emphysematous 
areas  was  found  a  gray-looking,  dirty  liquid 
mixed  with  gaseous  bubbles. 

Simple  incision  and  evacuation  of  these  liquid 
elements  would  not  have  sufficed  to  destroy  the 
soil  for  the  microbes,  inasmuch  as  the  slouofhino- 
tissues,  having  been  so  long  bathed  in  putrid 
fluid,  were  certainly  more  or  less  permeated  with 
it.  All  the  tissues  the  color  of  which  had  under- 
gone great  change,  especially  the  gray  and  black- 
ish-looking fascia  and  the  connective  tissue,  were 
removed.  A  large  sharp  curette  was  at  first 
employed  for  this  purpose.  After  this  manipu- 
lation, the  finger  being  often  employed  to 
explore  the  pockets  in.  the  deeper  layers,  the 
surfaces  were  wiped  with  gauze  mops  dipped 
in  an  8  per  cent,  solution  of  chloride  of  zinc. 
Iodoform  gauze  loosely  folded  together  was  then 
Introduced.     Bichloride   (i  :  20,000)   was  poured 


204  SURGICAL   ASEPSIS. 

into  the  gauze  every  hour  to  keep  It  continually 
well  moistened.  A  considerable  amount  of  ster- 
ilized gauze  saturated  with  bichloride  (i  :  looo) 
protected  the  packed  wound-surfaces  and  their 
vicinity,  thoroughly  covering  the  scrotum,  the 
penis,  the  upper  region  of  both  thighs,  and  the 
abdomen  and  the  lumbar  reofion  on  the  diseased 
side.  These  fomentations  of  the  i  :  looo  bichlo- 
ride solution  were  reapplied  every  hour. 

There  was  no  favorable  change  in  the  condi- 
tion of  the  patient  during  the  following  two  days, 
but  at  all  events  the  situation  did  not  change  for 
the  worse.  Above  the  right  trochanter  major  a 
red  spot,  painful  to  the  touch,  was  observed.  An 
exploratory  incision  was  made  immediately  after 
the  discovery  of  this  suspicious  point.  Deep 
under  the  fascia  was  found  necrotic  tissue  bathed 
in  a  thin,  brownish,  putrid  fluid.  The  whole  area 
was  treated  in  the  same  manner  as  was  the  field 
of  the  first  operation.  The  following  day  the 
pulse  fell  to  iio.  It  required  about  a  week  of 
repeated  removal  and  elimination  of  necrotic 
tissues  to  convert  the  wound-surfaces  into  a 
region  of  normal  orranulation. 

Dry  treatment  was  then  substituted  for  the 
moist  fomentations — that  is,  the  wound  was 
packed  with  dry  iodoform  gauze  and  covered 
with  sterilized  moss.  The  dressing  was  changed 
once  daily  during  the  following  week.     Later  on. 


ASEPTIC   OPEN-WOUND    TREATMENT.  205 

when   the   discharges   diminished,    the   dressings 
were  renewed  only  every  second  or  third  day. 

At  the  time  of  the  first  operation  cultures  were 
made  with  the  putrid  secretions.  After  the  cul- 
tures had  been  stained  with  fuchsin  there  were 
discovered  numerous  bacilli  connected  in  a  pecu- 
liar thread-like  fashion,  such  as  is  characteristic  of 
the  bacilli  of  malignant  oedema  (see  p.  44).  As 
these  micro-orcranisms  are  so-called  "  oblio^ate 
anaerobic  bacilli,"  it  is  evident  that  any  kind 
of  occlusive  treatment  would  only  have  favored 
their  further  development,  while  free  access  of 
the  inhibiting  oxygen  of  the  atmosphere  is  their 
main  destroying  factor.  Even  if  nothing  but 
free  incisions  had  been  made  and  only  the  ne- 
crotic elements  had  been  removed  mechanically, 
it  might  have  been  possible  to  prevent  further 
spreading  of  the  malignant  process. 

In  reference  to  the  use  of  the  sJiarp  spoon  the 
writer  may  be  allowed  to  call  attention  to  its 
great  usefulness,  not  only  on  account  of  its  value 
in  removing  foul  granulations,  but  also  as  regards 
its  diagnostic  merit.  Healthy  tissue  cannot  be 
scraped  away  if  only  the  ordinary  amount  of 
force  is  employed.  Thus  the  surgeon  may  form 
while  scraping  a  more  correct  opinion  of  the 
vitality  of  the  tissues  than  he  would  have  been 
able  to  do  before  the  foul  orranulations  were 
removed.       Aponeuroses,    fasciae,    tendons,    etc. 


206  SURGICAL    ASEPSIS. 

cannot,  of  course,  be  removed  with  the  sharp 
spoon,  forceps  and  scissors  being  required  for 
this  purpose. 

In  tubercular  processes  the  writer  regards  the 
open  treatment  as  the  ideal  method.  After  re- 
section of  a  tubercular  joint  or  after  extirpation 
of  tubercular  glands  suturing  should  only  par- 
tially be  performed,  and  then  only  in  very  large 
wounds.  All  the  pockets,  as  a  rule,  should  be 
loosely  but  well  packed  with  iodoform  gauze. 
The  gauze  may  remain  for  five  days  after  opera- 
tion if  there  be  no  particular  indication  for  an 
earlier  chano-e  of  the  dressinor. 

It  often  occurs  that  the  wound-surface  of  a 
tubercular  area  is  covered  by  a  layer  of  grayish 
granulating  tissue.  This  tissue  should  repeat- 
edly be  scraped  until  the  surfaces  show  a  tend- 
ency to  heal — that  is,  until  the  pale,  fungous 
granulations,  manifesting  no  reparative  tend- 
encies, have  disappeared  and  the  tissues  have 
become  firm  and  healthy.  When,  on  account 
of  local  relapse,  such  repeated  operations  are 
required,  strict  aseptic  precautions  must  be  ob- 
served, precisely  as  at  the  first  operation,  as 
tubercular  wounds  are  exceedingly  susceptible 
to  infection   by  pus-microbes. 

In  the  great  majority  of  cases  the  further 
course  of  treatment  demonstrates  the  peculiar 
antitubercular  influence  of  iodoform,  as  wounds 


ASEPTIC   OP  EN- WOUND    TREATMENT.  20/ 

treated  with  it  generally  heal  in  a  satisfactory 
manner  without  forming  fistulous  tracts.  Such 
influence  can  be  obtained  only  if  the  iodoform 
remains  in  close  contact  with  the  exposed  tis- 
sues. Further  remarks  on  the  antitubercular 
influence  of  iodoform  are  reserved  for  Section 
XIV.,  wherein  Aseptic  Injections  will  be  dis- 
cussed. 

In  laparotomies,  especially  in  operations  upon 
the  intestines,  drainage  with  iodoform  gauze  is 
of  the  utmost  value.  If,  after  resection  of  the 
intestine,  the  whole  sutured  area  is  well  covered 
with  two  strips  of  iodoform  gauze  reaching  to 
the  mesentery  on  each  side  of  the  intestine,  an 
excellent  protection  is  secured ;  consequently 
the  sutures  are  not  apt  to  cut  through  the  edges 
of  the  wound,  nor  is  it  probable  that  perforation 
by  a  suture  will  take  place.  Discharge  of  feces 
into  the  abdominal  cavity  may  thus  nearly  always 
be  prevented  ;  should  it  really  occur,  however, 
the  worst  result  would  be  a  fecal  fistula. 

The  iodoform  strips  should  be  conducted 
through  the  abdominal  wall  to  the  external 
surface.  The  writer  suggested^  fastening  pro- 
phylactically  with  two  fine  sutures  the  point 
of  the  intestinal  suture  to  the   abdominal  wall, 

1  "  Ueber  die  Behandlung  gangranoser  Hernien,"  Langenbeck's  Archiv 
filr  Chiriirgie,  xxv.  Bd.,  1880,  and  "  Resection  of  the  Intestine  in  Gan- 
grenous Hernia,"  N.  V,  Med.  Record,  April  8,  1893. 


208  SURGICAL   ASEPSIS. 

thus  enablinor  the  suroreon  to  find  the  suturinor 
point  easily  in  case  symptoms  of  separation 
should  appear  and  the  formation  of  a  fecal  fistula 
should  no  longer  be  avoidable.  This  method 
does  not  disturb  the  healing  process,  which  fact 
cannot  be  said  of  the  knot  proposed  by  Jobert. 

As  W.  Rindfleisch  has  shown  by  experiments 
on  animals,  a  sutured  intestine  generally  remains 
exactly  at  that  point  of  the  abdominal  wound 
where  it  has  been  placed.  On  the  basis  of  this 
observation  he  claims  that  prophylactic  sutures 
are  unnecessary.  However  this  may  be,  the 
writer  deems  it  safe  to  use  them.  They  cer- 
tainly facilitate  the  search  for  the  suturing  point 
if  secondary  operations  should  be  necessary. 

In  cases  of  operations  on  the  liver  or  the  gall- 
bladder the  strip  of  iodoform  gauze  can  seldom 
be  dispensed  with.  It  has  the  great  advantage 
of  absorbing  blood,  which  generally  oozes  in  con- 
siderable quantity  from  wounds  inflicted  upon 
these  oro-ans.  In  this  event  the  adhesiveness 
of  iodoform  gauze  proves  of  great  value,  as  it 
adheres  to  the  bleeding  surface  of  the  liver,  thus 
preventing  hemorrhage  into  the  peritoneal  cav- 
ity. The  gauze  may  be  left  in  the  cavity  for 
from  one  to  two  weeks,  and  as  soon  as  it  is  ex- 
tracted rapid  occlusion  ordinarily  takes  place,  so 
that  the  healing  process  does  not  require  much 
longer  than  if  primary  union  had  been  obtained. 


ASEPTIC   OPEN- WOUND    TREATMENT. 


209 


The  iodoform-gauze  strip  should  be  very  long, 
so  diat  only  a  single  piece  will  be  required.  It 
may  be  folded  together  and  be  pressed  against 
the  parenchyma.  A  small  end  of  the  strip  may 
then  be  led  through  an  interspace  left  between 
the  sutures  of  the  abdominal  wall.  In  excep- 
tional cases  it  may  be  impossible  to  attach  the 
gauze  tightly ;  it  may  then  be  fastened  to  the 
parenchyma  with  a  few  fine  sutures  applied  to 
the  capsule.  As  iodoform  gauze  adapts  itself 
tightly  to  the  serosa,  it  becomes  loosened  only 
when  the  discharges  grow  copious.  The  writer 
has  sometimes  kept  10  per  cent,  iodoform  gauze 
in  the  abdomen  for  two 
weeks,  at  the  expiration 
of  which  time  it  still  con- 
tained plenty  of  iodoform, 
and  bacterioloo^ical  inves- 
tigations  proved  it  to  have 
remained  sterile. 

Mikulicz  advised  the 
use  of  iodoform  gauze  in 
the  shape  of  a  gauze  bag 
(Fi^-  53)  ^s  a  very  effi- 
cient means  of  abdominal 
drainaore.  The bae should 
be  at  least  one  inch  wide 
and  from  six  to  ten  inches  lono--  The  bao-,  filled 
with  a  few  strips  of  iodoform  gauze,  of  a  width  of 


Fig.  53. — Mikulicz's  bag:  a, 
abdominal  sutures  ;  b,  gauze  bag ; 
c,  abdominal  wound  ;  d,  loops  in 
tlie  abdominal  wall ;  e,  gauze 
strip. 


14 


210  Si'KGICAL   ASEPSIS. 

about  two  inches,  or  with  iodoform  wicks,  should 
have  a  string  tied  to  its  lower  end.  After  an  ope- 
ration on  the  pelvic  organs  the  bag  is  placed  in 
the  pelvis,  across  that  part  requiring  drainage ; 
it  is  then  carried  over  the  fundus  uteri  and  led 
toward  the  outside  of  the  abdomen,  between 
the  sutures  in  the  abdominal  wall.  The  abdom- 
inal opening  can  be  separated  widely  by  pulling 
on  loops  conducted  through  each  edge  of  the 
abdominal  wound.  Capillary  attraction  brings 
the  secretion  to  the  surface,  where  it  is  absorbed 
by  a  thick  layer  of  gauze  or,  preferably,  by  ster- 
ilized moss-board,  the  latter  at  the  same  time 
acting  as  an  immobilizing  agent  (see  p.  122,  Fig. 
34).  The  strips  or  the  wicks  may  be  removed 
gradually — that  is,  some  on  the  day  following 
the  operation,  and  the  others  a  few  days  later,  as 
the  case  may  require.  Wicks  are  always  to  be 
preferred  on  account  of  their  greater  power  of 
absorption.  At  last  the  bag  itself  may  be  re- 
moved by  making  traction  upon  the  string  fast- 
ened to  the  bottom.  The  crreat  advantage  of 
this  method  over  drainage  by  rubber  and  glass 
tubes  is  its  continuous  and  automatic  action  as 
well  as  its  non-irritation.  Ordinary  hard  drain- 
age-tubes would  irritate  the  intestines,  the  ends  of 
glass  tubes  especially  exercising  great  pressure. 
Hemorrhage  from  the  large  venous  sinuses  of  the 
brain  can  seldom  be  stopped  except  by  packing 


ASEPTIC   OPEN-WOUND    TREATMENT.  211 

the  bleeding  surfaces  with  iodoform  gauze,  which 
must  remain  in  situ  for  at  least  one  week  before 
firm  union  of  the  walls  of  the  sinuses  takes  place. 

In  operations  upon  the  kidneys  the  iodoform- 
gauze  tampon  prevents  retention  of  discharges 
in  the  retro-peritoneal  space,  the  anatomical  con- 
dition of  which  favors  burrowlnof  of  the  dis- 
charges,  an  occurrence  which  in  this  particular 
region  would  nearly  always  lead  to  a  fatal  result. 

In  areas  such  as  the  i^ectiim,  wher^  the  tissues 
may  be  contaminated  by  the  constant  Inundation 
of  infectious  material,  the  iodoform  tampon  offers 
the  best  kind  of  protection.  What,  indeed,  would 
surgeons  do  to  cover  the  wound-surfaces  after  a 
resection  of  the  rectum,  of  the  superior  maxilla, 
or  of  the  tongue,  without  the  lodoform-gauze 
tampon  ? 

Methodical  temporary  packing  with  iodoform 
gauze  may  be  performed  In  all  cases  of  par- 
enchymatous hemorrhage.  After  resections,  in 
which  considerable  oozing  from  the  bone-tissues 
generally  takes  place  during  the  twenty-four 
hours  following  operation,  the  gauze  stops  hem- 
orrhage until  the  capillary  vessels  are  spontane- 
ously occluded  by  coagulation.  Twenty-four  to 
forty- eight  hours  after  such  operations,  if  no  evi- 
dence of  hemorrhage  is  present  and  if  the  wound- 
surfaces  appear  normal,  the  gauze  may  be  re- 
moved and  the  surfaces  may  be  coaptated  either 


212  SURGICAL  ASEPSIS. 

by  winding  iodoform-gauze  strips  around  them 
(see  p.  195),  If  the  edges  of  the  wound  can  thus 
be  approximated,  or  by  applying  secondary  su- 
tures. Iodoform  wicks  may  be  used  instead  of 
the  gauze,  on  account  of  their  greater  power  of 
absorption,  just  as  in  peritoneal  drainage.  Tem- 
porary packing  with  iodoform  gauze  very  often 
stops  hemorrhage  from  parenchymatous  surfaces 
much  more  efficaciously  than  does  the  Pacquelin 
cautery.  Gauze  mops  pressed  tightly  for  several 
minutes  against  the  bleeding  surface  in  operations 
on  parenchymatous  surfaces  like  even  that  of  the 
liver  (compare  p.  207)  generally  arrest  the  hem- 
orrhage entirely. 

RiMer  drainage-tubes  [cov^"^.  pp.  1 39, 1 90)  should 
be  used  only  when  the  employment  of  gauze  is 
impossible.  This  is  especially  the  case  in  large 
cavities  to  which  free  access  is  impossible  or  is 
very  difficult,  as  in  pyothorax,  for  instance  (see 
p.  234).  Here  the  surgeon  has  to  deal  with  a 
large  cavity  the  free  exposure  of  which  would 
require  such  extensive  operation  as  seriously  to 
endanger  the  patient's  life.  Were  this  not  the 
case,  thorough  packing  of  the  cavity  with  iodo- 
form gauze  would  be  the  proper  treatment. 
Therefore  other  than  the  usual  means  of  pre- 
venting retention  of  pus  must  be  employed.  To 
this  end  the  patient  should  always  lie  on  the  dis- 
eased side  of  the  thorax,  and  about  every  four 


ASEPTIC   OPEN-WOUND    TREATMENT.  213 

hours  should  be  Hfted  by  the  feet  to  compel  the 
pus  to  flow  into  the  dressing.  At  a  superficial 
glance  this  advice  may  appear  rather  strange, 
but  clinical  experience  shows  that  the  observ- 
ance of  this  procedure  is  apt  to  prevent  reten- 
tion, and  it  is  needless  to  urge  the  importance 
of  never  allowing  stagnation  of  pus  on. a  wound- 
surface  or,  especially,  in  a  cavity.  Thus  counter- 
openings,  as  advised  by  Kuester,  may  be  avoided. 
If  such  cavities  are  kept  wide  open,  the  introduc- 
tion of  a  dilating  speculum  such  as  advised  by 
the  writer  is  easy  and  allows  free  inspection  of 
them. 

The  writer  has  refrained  from  introducing  a 
rubber  drainage-tube  into  the  pleural  cavity  im- 
mediately after  resection  of  a  rib  in  pyothorax, 
as  he  has  witnessed  considerable  bleedino-  in 
consequence.  Moreover,  the  constant  respiratory 
movements  of  the  pleura  cause  irritation  by  fric- 
tion. Therefore,  three  days  after  operation  the 
writer  introduces  a  rubber  drain,  of  at  least  the 
size  of  a  man's  finger,  secured  by  two  large 
safety-pins  adjusted  in  the  shape  of  a  cross.  It 
seems  that  after  the  pleurae  become  accustomed 
to  contact  with  the  atmosphere,  and  as  soon 
as  granulations  appear,  they  bear  the  irritation 
well. 

Two  weeks  after  operation,  on  an  average,  a 
small  drain  is  introduced  and  is  gradually  short- 


214  SURGICAL   ASEPSIS. 

ened.  When  the  discharges  become  scanty  the 
drainage-tube  may  be  left  out  and  a  small  strip 
of  iodoform  gauze  may  be  substituted. 

Similar  principles  should  govern  the  intro- 
duction of  rubber  drains  after  perineal  or  supra- 
pubic section.  Posture  is  also  very  important  in 
such  cases.  The  patient  must  lie  in  a  position 
such  as  will  easily  allow  of  spontaneous  discharge 
of  the  urine.  If  a  rubber  drain  must  be  used,  it 
should  be  surrounded  with  iodoform  gauze  when- 
ever this  is  possible.  This  procedure  applies 
especially  to  infected  cavities,  such  as  a  bladder 
which  for  months  has  been  occupied  by  a  stone 
bathed  in  purulent  urine,  and  which  cannot  be 
rendered  aseptic  in  a  few  minutes  after  the  stone 
has  been  extracted  (see  p.  98).  In  such  a  case 
the  combination  of  iodoform  gauze  and  a  rubber 
drain  proves  especially  valuable. 

XII.  RENEWAL  OF  DRESSINGS. 

The  ideal  toward  which  the  modern  surgeon 
strives  is  primary  union  ;  consequently  he  ex- 
pects either  no  discharge  in  the  wounds  he  makes 
or  only  such  a  small  amount  of  discharge  as  will 
not  interfere  with  healing  under  a  single  dress- 
ing. The  less  frequendy  the  dressings  are 
changed,  the  more  agreeable  it  is  to  the  patient. 
Even    the   gentlest    renewal    cannot   but   cause 


'  RENEWAL    OF  DRESSINGS.  215 

some  pain  and  no  inconsiderable  possibility  of 
secondary  infection. 

The  main  indications  for  chanore  of  dressinor 
are  :  (i)  When  stitches  or  drainage-tubes  require 
removal ;  (2)  when  secondary  hemorrhage  oc- 
curs ;  (3)  when  discharges  become  so  abundant 
that  they  cannot  be  absorbed  by  the  dressings, 
consequently  transuding  to  the  surface  ;  (4)  when 
the  dressing  is  so  disturbed  that  either  the  pro- 
tection of  the  wound  becomes  imperfect  or  there 
is  risk  of  contamination  by  urine,  feces,  etc. ;  (5) 
when  the  patient  complains  of  considerable  pain  ; 
(6)  when  fever  sets  -in  and  general  symptoms 
point  toward  infection  ;  and  (7)  when  there  is 
any  doubt  as  to  the  character  of  the  fever.  In 
these  events  clinical  experience  seldom  fails  to 
guide  the  surgeon  properly. 

In  the  majority  of  cases  removal  of  the  stitches 
should  take  place  between  the  third  and  seventh 
days,  according  to  the  character  of  the  wound. 
After  delicate  plastic  operations  on  the  face  a  few 
sutures  may  be  removed  as  early  as  twenty-four 
hours  after  operation,  while  in  other  operations 
—  for  instance,  after  laparotomy  —  the  sutures 
should  remain  in  situ  for  at  least  one  week — 
as  a  rule,  from  ten  to  fourteen  days.  In  very 
long  ivounds,  or  in  those  where  there  is  danger 
of  sloughing  after  removal  of  the  sutures,  the 
stitches  should  be  taken  out  gradually — that  is, 


2l6  SURGICAL  ASEPSIS. 

only  a  few  sutures  at  the  place  of  least  tension 
should  be  removed  at  intervals  of  several  days. 
Manifestly,  when  rclaxatioii-siitures  are  used 
in  connection  with  continuous  sutures  the  inter- 
rupted relaxation-sutures  must  be  taken  out  first. 
Whenever  such  sutures  cut  through  the  skin  they 
must  immediately  be  removed. 

Removal  of  interrupted  sutures  is  performed 
by  seizing  one  end  of  the  knot  with  a  dissecting 
forceps  and,  while  slightly  drawing  upon  the 
knot,  cutting  through  the  loop  laterally  from 
the  line  of  incision  with  narrow-bladed  scissors. 
The  suture  may  then  be  drawn  out  slowly.  It 
may  easily  occur  that  an  overlooked  particle  of 
the  suture  remains.  This  accident  should  care- 
fully be  avoided. 

Continuous  sutures  can  much  more  easily  be 
removed  by  simply  drawing  them  out  after  cut- 
.  ting  through    the    exposed    por- 
tions between  the  stitch-canals. 

The  knot  (Fig.  54)  should 
always  be  conducted  above  the 
line  of  incision,  so  as  to  prevent 
separation    of   the  wound-edges, 

Fig.  54. — Extraction         i  •    i  •  •     i  -i   ' 

of  suture  which  separation  might  easily  oc- 

cur if  the  knot  were  drawn  out 
toward  the  opposite  side.  If  tension  threatens 
to  separate  the  lips  of  the  wound,  a  portion  of 
the  sutures  should  be  left  in  place  until  the  next 


RENEWAL    OF  DRESSINGS.  21/ 

removal,  when  they  must  be  examined  thor- 
oughly. If  some  tension  ts  still  present,  the 
sutures  may  be  left  until  a  subsequent  change 
of  dressing,  otherwise  they  may  be  extracted  at 
once.  If  catgut  be  used,  these  procedures  are 
unnecessary,  as  that  part  of  the  suture  imbedded 
in  the  tissues  will  be  absorbed,  so  that  only  the 
portion  of  the  suture  remaining  on  the  surface 
need  be  lifted  from  the  skin  with  forceps.  After 
removinof  the  sutures  the  wound  should  be 
covered  with  sterilized  gauze.  Wiping  or  press- 
ing the  wound,  irrigation,  or  other  manipulation 
should  be  avoided.  The  modern  suro^eon  is 
characterized  by  doing  little  on  the  aseptic 
wound  itself,  and  much  around  it. 

A  clean  wound  healing  by  first  intention  should 
never  show  the  slightest  reaction.  The  edges 
should  be  neither  reddened  nor  swollen,  nor 
should  any  infiltration  be  present.  No  pain 
is  ever  associated  with  a  wound  thus  healed. 
Alonor  the  line  of  union  as  well  as  alonorside 
the  sutures  dried  blood  and  serum  are  all  that 
will  be  found.  The  inner  layer  only  of  the  gauze 
protectinor    the    wound-surface    should     contain 

i  O 

a  small  amount  of  odorless  and  dried  serum. 
The  first  layer  of  gauze — that  is,  the  one  put 
immediately  upon  the  united  wound — may  be 
protected  by  a  second  layer  of  gauze,  or,  prefer- 
ably, by    sterilized    moss-board,  which    has    the 


2l8  SURGICAL  ASEPSIS. 

advantage  of  supporting  and  immobilizing  the 
parts. 

The  secondary  dressing  of  a  wound  healed  by 
first  intention  should  be  completed  over  a  smaller 
area  than  the  first  dressing,  and  it  should  be  ap- 
plied in  the  same  manner  as  is  done  immediately 
after  operation,  since  hardly  any  further  dis- 
charge is  to  be  expected.  Four  or  five  days 
later  the  dressing  may  again  be  removed.  Such 
sutures  as  were  left  at  the  time  of  the  latest 
removal  may  then  be  taken  out.  If  the  sutures 
have  been  removed  completely  at  the  first  re- 
newal of  dressing,  there  will  remain  only  a  nar- 
row line  indicatincr  the  incision.  The  dressinor 
may  then  be  dispensed  with  entirely,  or,  in  case 
there  is  found  some  excoriation  of  the  stitch- 
canals  or  of  the  vicinity  of  the  wound,  there  may 
be  applied  a  non-irritating  adhesive  such  as  the 
yellow  adhesive  plaster. 

Wounds  which  were  united,  but  into  the  cor- 
ners of  which  small  drainaoe-tubes  had  been 
inserted,  present  about  the  same  appearance  as 
those  which  were  sewed  up  entirely.  After  ope- 
rations, as  amputatio  mammae,  in  which  buried 
sutures  alone  do  not  suffice  to  prevent  the 
formation  of  pockets  (possibly  beneath  the  la- 
tissimus  dorsi  and  on  the  anterior  surface  of 
the  thorax),  drainage  must  be  employed.  This 
is   best    effected    by   the    introduction    of   gauze 


RENEWAL    OF  DRESSINGS.  219 

draijts,  but  some  surgeons  prefer  very  small 
rubber  drains,  which  must  be  removed  at  the 
first  renewal  of  the  dressing.  Sterilized-gauze 
mops  should  then  be  kept  in  readiness  to  wipe 
off  the  serous  discharge  from  the  small  openings. 
Wounds  of  this  kind  should  present  as  little  irri- 
tation as  those  previously  described,  from  which 
they  differ  only  in  discharging  more  copiously 
into  the  gauze.  But  this  discharge  has  gener- 
ally dried  at  the  time  of  the  first  re-dressing. 
Sometimes  even  the  gauze  drain  is  dry,  or  is 
but  slightly  moistened  with  a  sero-sanguinolent 
discharge. 

In  the  absence  of  infection  the  wound-canals 
formed  by  the  drain  will  be  found  free  of  pus, 
although  they  may  be  filled  with  granulations. 
After  having  removed  the  gauze  drain  it  is  ad- 
visable to  introduce  a  smaller  one,  provided  the 
discharge  is  scanty.  Instead  of  removing  the 
gauze  strip,  it  may  be  pulled  out  to  a  slight 
extent  and  be  shortened  with  scissors  at  the 
time  of  the  first  renewal,  and  be  removed  en- 
tirely at  the  second  change  of  the  dressing. 
The  same  principles  apply  when,  exceptionally, 
rubber  drainage  is  used. 

A  gauze  drain,  when  introduced  too  tightly, 
is  sometimes  apt  to  occlude  the  canal  entirely, 
thus  causing  the  very  retention  it  is  desired 
to  prevent,  or,  if  there  are  several  sinuses,  one 


220  SURGICAL   ASEPSIS. 

or  the  other  may  close  spontaneously,  thereby 
retainhig  the  fluid  wound-products.  Mild  symp- 
toms of  retention  then  frequently  supervene ; 
when  they  occur,  immediate  removal  of  the 
gauze  is  indicated.  In  such  a  case,  as  soon  as 
the  gauze  drain  is  drawn  out  with  the  forceps 
the  retained  discharge  generally  follows.  If  this 
should  not  occur,  careful  palpation  will  often  in- 
dicate the  seat  of  retention,  toward  which  a  thin 
forceps  should  then  be  guided  to  separate  the 
adhesions  and  to  permit  the  free  discharge  of 
the  retained  fluid.  The  wound  should  then  be 
repacked  loosely.  Occasionally  a  rubber  drain 
surrounded  by  gauze  may  be  employed  satisfac- 
torily, but  only  for  a  few  days,  as  it  is  expected 
that  after  the  discharge  has  lessened  the  gauze 
may  be  substituted  again. 

In  removing  sutures  in  such  cases  procedures 
are  in  order  similar  to  those  advised  in  com- 
pletely united  wounds. 

Seco7tdaiy  hemorrhage  is  another  indication  for 
removing  the  dressing.  In  wounds  which  were 
sewed  up  entirely  secondary  hemorrhage  is  gen- 
erally due  to  lack  of  thoroughness  in  ligating 
the  vessels,  but  it  may  be  caused  also  by  the 
coming  away  of  a  ligature  due  to  some  move- 
ment of  the  wounded  part,  or  in  exceptional 
cases  by  the  action  of  the  heart  in  driving  out 
coagula  from  the  end  of  a  divided  vessel. 


RENEWAL    OF  DRESSINGS.  221 

In  open  wounds  hemorrhage  may  be  caused 
by  disease  of  the  walls  of  a  vessel  or  by  slough- 
ing or  ulceration  or  septic  infection  of  the  wound. 
Too  rapid  absorption  of  catgut  ligatures  also  fur- 
nishes a  quite  frequent  source  of  parenchyma- 
tous or  capillary  hemorrhage.  It  may  also  be 
caused  by  persistent  bleeding  which  during  ope- 
ration was  arrested  only  temporarily  and  super- 
ficially by  tamponing. 

In  large,  deep  cavities  it  may  be  impossible  to 
apply  ligatures  to  a  bleeding  artery.  Atheroma- 
tosis may  also  render  the  vessel  so  brittle  that 
the  ligatures  cut  through  instead  of  constricting 
it.  Exceptionally  there  may  be  other  reasons 
that  compel  the  surgeon  to  resort  to  the  gauze 
tampon.  The  dressing  must  then  be  applied 
very  tightly,  and,  if  necessary,  it  may  be  sup- 
ported by  marine  sponges.  Naturally,  when 
such  conditions  are  observed  during  operation, 
the  surgeon  should  be  prepared  for  secondary 
hemorrhage  after  the  close  of  the  operation. 

Hemorrhage  may,  however,  set  in  without  any 
perceptible  cause,  or  it  may  be  caused  by  any- 
thing that  is  likely  to  increase  pressure  on  the 
circulation — that  is,  by  coughing,  by  strangling, 
or  by  any  other  violent  effort.  It  is  thus  evident 
that  dressings  applied  under  these  circumstances, 
especially  to  the  posterior  and  most  dependent 
parts   of    wounds,   must    be    watched   with    the 


222  SURGICAL   ASEPSIS. 

Utmost  care,  and  after  the  dressing  has  been  re- 
moved a  new  layer  of  gauze  must  be  pressed 
tightly  against  the  wound-surfaces.  If  this  pro- 
cedure does  not  prove  successful,  the  gauze  tam- 
pons introduced  immediately  after  operation 
must  be  removed.  New  strips  must  now  be  in- 
troduced with  a  dressing-forceps,  by  which  the 
gauze  can  be  forced  in  much  more  tightly  than 
by  any  other  instrument. 

Should  blood  flow  freely  from  the  wound,  the 
sutures  must  be  cut  through  and  the  edges  of 
the  wound  be  separated  instandy.  If  hemorrhage 
takes  place  from  an  extremity,  an  Esmarch  band- 
age or  some  variety  of  tourniquet  should  at  once 
be  applied  (see  p.  194).  This  compression  will 
materially  facilitate  the  procedures  afterward  to 
be  carried  out.  The  clots  filling  the  cavity  are 
turned  out  rapidly  by  wiping  the  surfaces  with 
gauze  mops,  so  that  a  clear  view  of  the  region 
may  be  obtained.  If  the  wound  is  not  too  deep 
nor  too  irregular,  the  source  of  the  hemorrhage 
will  soon  be  discovered.  If  the  source  of  the 
hemorrhage  be  a  vessel,  it  must  be  tied.  If  its 
brittleness  or  its  close  attachment  to  a  bone,  or 
any  other  reason,  renders  impossible  the  encir- 
cling of  the  vessel  with  a  ligature,  it  must  be 
caught  up  by  an  artery-forceps,  which  may  be 
left  ill  situ.  The  wound  must  then  be  kept  well 
open  and  be  dressed  in    this  condition.     Thor- 


RENEWAL    OF  DRESSINGS.  223 

ough  packing  with  gauze  is  often  successful  after 
failure  to  control  the  bleeding  by  the  above 
methods  or  after  having  passed  sutures  under 
the  tissues  containingr  the  vessel. 

After  laparotomy  hemorrhage  will  only  excep- 
tionally be  discovered  at  its  onset ;  consequently 
the  chances  for  reopening  the  abdominal  cavity 
are  very  unfavorable,  as  the  patient  will  have  lost 
a  great  amount  of  blood  before  the  symptoms 
of  internal  hemorrhage  are  well  developed. 
Drainage  after  laparotomy  reveals  secondary 
hemorrhage  much  more  readily  and  earlier  than 
in  cases  in  which  it  is  omitted.  The  blood-satu- 
ration of  the  gauze,  however,  is  not  necessarily 
an  index  of  the  amount  of  blood  being  lost;  this 
is  indicated  better  by  the  constitutional  symp- 
toms, which  will  be  the  same  as  those  of  any 
other  concealed  hemorrhage ;  their  gravity  will 
decide  the  question  as  regards  reopening  the 
abdomen. 

A  very  frequent  indication  for  the  renewal  of 
dressings  is  that  in  which  the  discharges  are  so 
abundant  as  to  inhibit  further  absorption.  As  a 
rule,  after  operation  on  large  cavities,  where  the 
edges  can  be  united  only  partially  or  where  the 
surgeon  is  compelled  to  leave  the  wound  entirely 
open,  according  to  the  principles  described  in  the 
preceding  section,  a  considerable  amount  of  dis- 
charge  must  be   expected.      The  first  dressing 


224  SURGICAL   ASEPSIS. 

must  then  be  chano^ed  In  two  to  four  davs.  In 
such  cases,  on  removing  the  dressnig  its  outer 
layers  are  partially  saturated  with  an  odorless 
and  sanguinolent  discharge,  while  the  inner  layers 
contain  an  abundant  discharge.  The  gauze  situ- 
ated directly  upon  the  wound-surfaces  generally 
contains  purulent  fluid  in  addition  to  the  sero- 
sanguinolent  liquid. 

In  that  portion  of  the  wound  united  by  sutures 
such  perfect  primary  union  may  have  been  ob- 
tained that  the  sutures  may  safely  be  taken  out. 
The  gauze,  if  saturated  with  the  sero-sanguino- 
lent  or  the  suppurative  discharge,  may  then  be 
drawn  out  with  a  dressing-forceps,  and  either  be 
shortened  or,  if  the  discharge  is  abundant,  be  re- 
moved altogether  and  fresh  gauze  be  substituted. 
If  the  principles  described  in  Section  XL,  on 
Open-wound  Treatment,  especially  in  reference 
to  gauze  packing,  or  to  thorough  removal  of 
necrotic  tissue,  were  not  rigidly  observed,  it  may 
occur  that  by  drawing  the  gauze  strips  forward 
some  retained  fluid  will  be  evacuated.  This 
fluid  may  be  mopped  into  sterilized  pus-basins  or 
be  taken  up  by  pieces  of  gauze  surrounding  the 
margins  of  the  wound. 

After  having  the  whole  field  wiped  clean  of  dis- 
charges another  dressing  should  be  applied  ex- 
actly as  that  directed  after  an  operation.  After 
the  lapse  of  from  three  to  six  days  the  dressing 


RENEWAL    OF  DRESSINGS.  225 

must  again  be  renewed  if  the  amount  of  dis- 
charge is  sufficiently  great  to  require  renewal. 
Decrease  of  the  discharge,  which  will  then  have 
lost  its  sero-sanguinolent  character  and  have  be- 
come entirely  purulent,  may  be  expected.  The 
wound-cavities  will  generally  have  become  much 
smaller  by  this  time,  as  they  are  being  filled  by 
granulations  exactly  as  in  superficial  wounds  of 
the  skin. 

At  the  second  change  of  the  dressings  on 
wounds  producing  abundant  discharge  there 
may  be  removed  all  the  sutures  not  taken  out 
at  the  first  removal.  A  strip  of  iodoform  gauze, 
smaller  than  the  one  used  at  first,  may  be  intro- 
duced loosely  into,  and  be  kept  in,  the  cavity, 
which  may  be  in  the  same  condition  now  as  a 
common  aseptic  wound,  described  above,  so  that, 
consequently,  it  can  be  treated  after  the  same 
principles — that  is,  at  intervals  of  from  three  to 
six  days  the  same  operation  may  be  repeated 
until  the  cavity  is  occluded  by  granulations. 

If  during  the  after-treatment  no  micro-organ- 
isms have  entered  the  wound-cavity,  the  discharge 
becomes  serous  and  scanty  and  the  wound-sur- 
faces are  glued  together  at  all  the  coaptated  points. 
Where  no  such  agglutination  takes  place  granu- 
lation tissue  will  be  produced  until  the  cavity  is 
entirely  filled  with  it.  Suppuration  does  not 
necessarily   take    place    under    such    conditions, 

15 


226  SURGICAL   ASEPSIS. 

hence  this  manner  of  heaHng  by  second  intention 
does  not  differ  materially  from  direct  union  by 
first  intention.  As  a  matter  of  experiment,  in 
resection  of  a  tuberculous  knee-joint  the  writer, 
after  thoroughly  packing  all  cavities  with  iodo- 
form gauze  and  after  surrounding  the  whole  leg 
with  a  large  piece  of  sterilized  moss,  left  the 
dressing  undisturbed  for  three  weeks.  After  the 
lapse  of  this  period  of  time  a  slight,  somewhat 
odorous  discharge  was  observed  on  the  outer 
surface  of  the  dressing.  When  the  latter  was 
removed  the  wound  appeared  perfecdy  normal. 
No  microbes  could  be  cultivated  from  the  gauze 
covering  the  wound-surface,  and  no  smell  except 
that  of  iodoform  could  be  detected  in  this  por- 
tion of  the  dressing. 

Dressings  occasionally  produce  dermatoses. 
Thus,  eczema  may  result  from  retained  perspi- 
ration or  from  the  irritant  influence  of  antisep- 
tics. These  eruptions  naturally  make  renewal 
of  the  dressings  obligatory.  The  first  of  the 
above-mentioned  causes  may  give  rise  to  simple 
dermadds,  which  renders  imperative  a  change  of 
dressing  and  appropriate  local  treatment.  In- 
tense irritadon  of  the  skin  may  result  from 
employing  as  a  fomentadon  bichloride  of  mer- 
cury, in  which  event  the  substitution  of  another 
andseptic  is  indicated. 

Iodoform  (see  p.  86)  may  also  produce  eczema, 


RENEWAL    OF  DRESSINGS.  22/ 

especially  in  individuals  who  have  a  peculiar 
predisposition  to  this  form  of  dermatitis.  The 
writer's  experience  at  the  German  Polikinik  in 
New  York  City  shows  that  about  two  patients  in 
each  hundred  are  likely  to  acquire  eczema  from 
the  use  of  iodoform.  If  such  patients  are  care- 
fully watched  the  eczema  seldom  acquires  such 
headway  that  it  cannot  easily  be  checked  by 
merely  discontinuing  the  iodoform  and  substi- 
tuting sterilized  gauze.  The  writer  commonly 
uses  salicylated  gauze  until  the  eczema  is  healed. 

The  main  symptoms  indicating  the  formation 
of  eczema  tmder  a  dressing  are  burning  and  itch- 
ing sensations,  which  may  be  so  intense  that  the 
patient  cannot  resist  the  temptation  to  scratch 
the  part  even  through  the  most  carefully-ad- 
justed dressing.  Manifestly,  this  act  is  likely 
to  interfere  seriously  with  asepsis,  and  it  is 
ample  indication  for  the  immediate  change  of 
such  dressings. 

It  seems  to  the  writer  that  most  cases  of  iodo- 
form eczema  are  generally  unrecognized  at  their 
earliest  stage— a  deplorable  fact  that  may  lead 
to  serious  complications.  The  text-books  do  not 
materially  aid  in  forming  a  judgment  of  these 
eruptions,  which,  although  they  generally  are  of 
an  erythematous  character,  may  assume  the  pap- 
ular and  urticarial  as  well  as  the  petechial  form, 
or  which  may  even  develop   vesicles.     The  der- 


228  SURGICAL   ASEPSIS. 

matitis  at  first  is  confined  to  the  site  of  the 
appHcation  of  the  iodoform,  but  it  may  ultimately 
spread  over  the  whole  body. 

Most  patients  acquire  eczema  only  after  iodo- 
form has  been  used  for  several  days  or  even  for 
weeks.  In  the  case,  for  instance,  of  a  little  boy 
whose  great  toe  was  crushed  by  an  elevator,  the 
attending  physician  removed  the  bone-fragments 
at  once  and  dressed  the  wound  with  iodoform 
powder  and  gauze.  The  patient  did  well  for  five 
weeks  under  this  treatment,  and  the  wound  had 
nearly  healed,  when  suddenly  the  toe  and  its 
adjacent  parts  became  red,  swollen,  and  painful. 
The  physician  told  the  parents  of  the  boy  that 
for  some  unknown  reason  trouble  had  arisen  in 
the  bone.  He  thouo^ht  his  treatment  had  not  been 
sufficiently  antiseptic,  and  he  tried  to  correct  this 
supposed  deficiency  by  applying  a  quantity  of 
iodoform  powder  greater  than  before.  Conse- 
quently, on  the  day  following  the  application  the 
whole  foot  was  extensively  swollen.  The  physi- 
cian thought  that  he  still  had  not  done  enoucrh 
iodoformization,  and  he  then  anointed  the  whole 
extremity  with  iodoform  vaseline.  When,  after 
this  last  application,  the  process  became  diffused 
over  the  leg,  vesicles  appeared,  and  pain  in  the 
groin  indicated  swelling  of  the  inguinal  glands, 
the  physician  became  frightened  and  suggested 
amputation  of  the  toe.     This  advice,  fortunately, 


RENEWAL    OF  DRESSINGS.  229 

was  not  followed,  but  another  physician  was 
called  in,  with  whom  the  writer  saw  the  case  in 
consultation.  It  caused  the  writer  some  trouble 
to  convince  his  colleague  that  there  was  neither 
an  inflammatory  process  in  the  bone  nor  erysip- 
elas, but  that  the  erythematous  eruption  and  the 
little  vesicles  were  due  to  the  iodoform.  The 
whole  treatment  for  the  following  three  days 
consisted  simply  in  doing  away  with  the  drug, 
and  perfect  recovery  followed  within  a  few  days. 

Some  cases,  moreover,  quickly  show  a  most 
decided  and  rapidly-spreading  eruption,  even 
after  minimal  quantities  only  are  applied.  This 
rare  type  the  writer  used  to  term  the  "foudroy- 
ant."  In  cases  of  this  kind  the  dermatitis  may 
spread  over  the  whole  body  within  a  few  hours, 
and  it  must  then  be  considered  quite  serious. 

Laborers,  machinists,  etc.,  whenever  injured, 
should  be  asked,  before  applying  an  iodoform 
dressing,  whether  previous  injuries  were  followed 
by  eczema  in  consequence  of  using  the  "yellow 
powder  of  offensive  odor." 

The  writer  can  recall  a  number  of  individuals 
— laborers,  machinists,  etc.,  who,  on  account  of 
the  dangerous  nature  of  their  business,  are 
exposed  to  repeated  injury — who  are  aware  of 
their  susceptibility  to  iodoform,  and  who  have 
acquired  such  a  dread  of  iodoform  eczema  that 
after  an  accident  they  implore  the  surgeon  not 


230  SURGICAL   ASEPSIS. 

to  use  iodoform  in  dressing  die  wound.  This 
idiosyncrasy  is  sometimes  developed  to  an  extra- 
ordinary extent.  The  writer  knows  of  several 
physicians  who  are  apt  to  acquire  an  eczema 
from  merely  touching  iodoform  gauze. 

If  the  dermatitis  is  so  intense  that  oedema, 
infiltration,  pain,  and  fever  appear,  a  differen- 
tiation from  septic  erythema  or  from  erysipelas 
may  be  difficult.  In  such  a  case  it  should  espe- 
cially be  remembered  that  in  erysipelas  the  mar- 
gins of  the  vesicles  are  wall-like  elevations. 

Necrosis  of  the  margins  of  the  wound  may  set 
in  when  they  are  insufficiently  nourished  in  con- 
sequence of  the  cutting  off  of  their  blood-supply. 
(Compare  Section  XL,  on  Open-wound  Treat- 
ment, p.  183.)  Such  an  occurrence  is  apt  to  result 
after  plastic  operations,  amputations,  etc.,  espe- 
cially if  the  base  of  the  skin-flap  is  too  narrow  or 
if  the  sutures  are  applied  so  tightly  that  circula- 
tion is  impaired  by  pressure.  Diabetes  particu- 
larly favors  this  condition.  In  such  a  case  the 
sutures  must  be  taken  out  and  the  necrotic  por- 
tions of  the  wound  must  be  removed.  If  for  any 
reason  the  suspicious-looking  portions  cannot 
be  removed,  they  should  at  least  be  dusted  with 
iodoform  or  be  surrounded  by  iodoform  gauze, 
which  has  no  disinfectin^r  influence  in  itself,  but 
which  represents  a  protection  apt  to  prevent 
further  infection  of  the  adjacent  wound-surfaces. 


RENEWAL    OF  DRESSINGS.  23 1 

Necrotic  wound-surfaces  are  best  treated  ac- 
cording to  the  principles  enunciated  in  Section 
X.,  on  Infected  Wounds  (p.  172),  and  no  oc- 
clusive dressing  should  be  applied.  Iodoform 
gauze  is  introduced  loosely  into  the  cavities  and 
is  renewed  at  least  once  a  day.  While,  as  a  gen- 
eral principle,  dressings  should  be  changed  as 
rarely  as  possible,  in  regard  to  necrotic  wound- 
surfaces  the  opposite  view  must  be  taken  until 
they  have  assumed  a  healthy  condition. 

A  few  words  regarding  suhires  may  here  ap- 
propriately be  added.  If  the  sutures  have  cut 
throuofh  the  skin  so  that  the  wound  slouorhs, 
they  must  be  removed  entirely.  It  then  becomes 
a  matter  of  choice  either  to  let  the  wound-cavity 
heal  by  granulation  or  to  unite  it  again  by  sec- 
ondary sutures  after  freshening  the  surfaces  ;  this 
latter  procedure,  however,  will  only  exception- 
ally be  successful.  It  is  only  after  operations 
for  hare-lip  (where  partial  sloughing  is  of  quite 
frequent  occurrence)  that  such  secondary  sutures 
have  rendered  the  writer  valuable  service. 

Silk  or  catgut  sutures  which  have  not  been 
sterilized  thoroughly  are  not  infrequently  the 
sources  of  infection  followed  by  suppuration  in 
the  stitch-canals.  Cuttino-  throuorh  the  sutures 
favors  suppuration,  which  may  take  place  super- 
ficially as  well  as  in  the  bottom  of  the  cavity 
when  buried  sutures  are  used.     If  suppuration 


232  SURGICAL   ASEPSIS. 

is  only  superficial,  the  pus  may  escape  sponta- 
neously through  the  stitch-canals,  and  conse- 
quently the  general  condition  of  the  patient  need 
not  necessarily  be  impaired.  Deep-seated  sup- 
purating sutures  naturally  cause  great  disturb- 
ance of  the  general  condition  of  the  patient, 
such  as  fever  (up  to  103°  F.),  violent  pain,  loss 
of  appetite,  etc.  If  the  dressing  is  changed,  the 
tissues  will  be  found  reddened  and  will  show 
extensive  infiltration.  Collateral  oedema  is  sel- 
dom absent,  in  which  case  dilatation  of  tlie 
wound-canal  with  the  forceps,  or  incision,  is  called 
for  to  allow  the  pus  to  escape. 

If  there  is  much  dischm^ge,  the  dressing  should 
be  changed  at  least  once  a  day.  If  much  inflafn- 
mation  be  present,  antiseptic  fomentations  (pref- 
erably of  the  acetate  of  aluminum)  should  be 
used,  after  loosely  packing  the  cavities  with 
iodoform  gauze,  until  the  inflammatory  symp- 
toms have  subsided  ;  a  dry  dressing  may  then 
be  employed.  Sometimes  granulations  form  so 
abundantly  as  to  require  their  removal  with  a 
sharp  curette. 

If  stasis  In  circulation  takes  place,  the  granu- 
lations assume  a  dark-red  or  a  bluish  appear- 
ance and  finally  break  down  into  foul  ulcers. 
This  result  occurs  especially  in  varicose  ulcers 
of  the  leg,  where,  Instead  of  normal  red  granula- 
tions, there  Is  found  a  gray  surface  covered  with 


RENEWAL    OF  DRESSINGS.  233 

debris  and  necrotic  tissue.  Naturally,  there  is  no 
tendency  to  the  formation  of  skin-tissue  until  this 
more  or  less  infectious  material  is  all  removed 
by  scraping  and  until  firm  and  healthy  tissue  is 
reached.  The  writer  found  it  useful  to  apply 
an  8  per  cent,  chloride-of-zinc  solution  to  such 
surfaces  after  curetting.  (Compare  Section  III., 
on  Means  of  Disinfection,  p.  68.) 

The  writer  generally  applies  either  iodoform 
or  sterilized  eauze  to  the  surface  after  the  bleed- 
ing  has  been  stopped  by  pressure,  the  gauze 
being  protected  with  a  large  piece  of  dry  steril- 
ized moss  secured  by  a  gauze  bandage.  The 
dressino-  is  then  drenched  with  a  weak  solution 
of  bichloride  or  of  acetate  of  aluminum  to  make 
the  moss  swell,  by  which  means  continuous  press- 
ure is  exerted  upon  the  ulcer;  this  pressure  is 
sustained  by  saturating  the  moss  with  the  liquid 
every  few  hours.  Pressure  in  itself  being  a 
decided  and  well-known  healing  factor,  it  can 
thus  advantageously  be  combined  with  such 
antiseptic  fomentation. 

If  the  extremity  is  not  entirely  encircled  by  the 
moss,  the  circulation  does  not  become  endan- 
gered. When  the  ulcerated  groove  begins  to 
fill  and  the  discharge  grows  scanty  an  ordinary 
adhesive  plaster  and  a  compressive  bandage  may 
be  substituted.  The  same  principles  of  treat- 
ment may  be  followed  out   at    other  points,  as 


234  SURGICAL    ASEPSIS. 

well  as  in  similar  conditions — for  instance,  in 
tuberculous  or  specific  ulcers. 

As  a  rule,  such  dressings  should  be  performed 
daily  until  the  granulations  assume  a  healthy 
appearance.  Tuberculous  as  well  as  specific 
ulcers  must  be  scraped  repeatedly,  and  until  a 
satisfactory  state  is  obtained  the  dressings  should 
be  renewed  frequently,  at  least  for  inspection. 
Of  course,  in  such  cases  constitutional  treatment 
should  be  employed  at  the  same  time.  If  rubber 
drains  are  used  in  large  cavities,  the  tube  should 
gradually  be  shortened.  In  cases  where — as  in 
pyothorax,  for  instance  (see  p.  212) — resection  of 
a  rib  has  been  performed,  a  drainage-tube  smaller 
than  the  one  first  used  is  generally  required  two 
weeks  after  operation  ;  after  another  week  this 
tube  also  must  be  shortened.  When  the  dis- 
charge becomes  at  last  serous  and  scanty  the 
tube  may  be  dispensed  with  and  a  small  strip  of 
iodoform  gauze  or  a  wick  be  substituted  for  a 
day  or  two. 

For  the  next  few  days  the  patient  must  be 
watched  very  carefully.  The  cavity  may  be  ob- 
literated after  twenty-four  hours,  but  very  often 
the  union  is  only  superficial,  and  there  occurs 
retention  of  pus,  which  is  manifested  by  an  ele- 
vation of  temperature.  The  drainage-tube  must 
now  be  re-introduced,  and  after  a  week  the  short- 
ening of   the  drainage-tube    must   be    repeated 


RENEWAL    OF  DRESSINGS.  235 

until,  four  days  after  the  obliteration  of  the  pus- 
cavity,  no  discharge  appears  and  the  temperature 
remains  normal.  In  doubtful  cases  the  grooved 
director  may  reveal  the  presence  of  retained  pus. 

The  dresslnor  of  such  larcre  cavities  must  be 
changed  about  twice  a  day  for  the  first  week, 
later  on  once  a  day,  and  after  three  weeks  it  wnll 
suffice  to  change  the  dressing  every  second,  third, 
or  fourth  day. 

As  has  been  shown,  the  open-wound  treatment 
is  the  treatment  par  excellence  for  compound  frac- 
tures. In  cases  where  much  displacement  is 
present  frequent  change  of  dressing  is  Indicated, 
to  permit  repeated  inspection  of  the  bone-frag- 
ments, which,  should  they  be  displaced  again, 
may  thus  easily  be  returned  to  their  proper 
places. 

For  cases  in  which  union  fails  to  take  place  the 
writer  has  devised  a  canaliculated  metal  splint 
whose  concavity  fits  the  convexity  of  the  bone- 
fragments,  upon  which  the  splint  is  fastened  with 
a  few  screws  (Fig.  55). 

This  metal  splint  when  in  situ  embraces  the 
bones  to  the  extent  of  three-quarters  of  their 
periphery,  and  must  then  be  protected  on  Its 
exterior  surface  with  iodoform  gauze,  which  must 
be  renewed  about  once  a  week.  Four  weeks 
after  the  splint  has  been  screwed  on,  when  at 
least  superficial  consolidation  may  be  expected, 


236  SURGICAL  ASEPSIS. 

an  effort  to  extract  the  splint  is  made.     If  the 

opening  has  been  kept  widely  separated  by  the 

gauze,  the  extraction  will  be  easy. 

When  pain  is  complained   of   there   must   be 

somethine  wrons:  in  the  wound,  which  then  re- 
quires  renewal  of  the  dressing, 
at  all  events  for  exploratory  pur- 
poses. 

The  thermometer  Is  often  a 
good  guide  in  treatment.  Ele- 
vation of  tempei'ature  demands 
immediate  change  of  the  dress- 
ings. Shortly  after  the  removal 
of  the  dressing  from  suppurating 
wounds  a  sliorht  elevation  of  tem- 
perature  usually  results  as  the 
„  ,  .      natural  expression  of  the  irrita- 

FlG.  55. — Posterior      ^  ^ 

view  of  Beck's  ex-  tion  of  the  wound.  Therefore,  if 
tractable  bone-splint  ^q  constitutional  disturbance  of 
any  kind  be  observed,  this  symp- 
tom would  be  no  indication  to  renew  the  dressing 
before  the  third  or  fourth  day  after  operation. 

The  principles  of  prophylactic  disinfection 
described  in  Section  IV.  must  be  observed  when 
a  dressing  is  renewed,  and  the  preparations 
should  be  identical  with  those  made  for  an  ope- 
ration. Before  touching  the  dressing's  the  hands 
must  be  disinfected  thoroughly.  A  nurse  should 
cut  through   the    bandages   and    the    superficial 


RENEWAL    OF  DRESSINGS.  237 

layers  of  the  gauze  with  the  bandage-scissors. 
The  surgeon,  using  steriUzed  forceps,  then  raises 
the  gauze  directly  overlying  the  wound. 

It  is  inexcusable  for  a  surgeon  to  follow  asep- 
sis half-heartedly  or  to  omit  precautions  on  the 
score  of  these  being  unnecessary,  even  though 
a  wound  be  septic.  If  the  hands  are  not  disin- 
fected, they  may  carry  pathogenic  microbes  of 
greater  virulence  than  those  with  which  the 
wound  was  originally  infected. 

All  re-dressing  should  be  done  with  sterilized 
instruments,  the  hands  being  always  kept  asep- 
tic. Whenever  the  hands  become  contaminated, 
they  must  again  be  disinfected  as  thoroughly  as 
before.  The  whole  vicinity  of  the  wound  should 
be  protected  with  sterilized  towels  after  the  part 
surrounded  by  the  dressing  has  been  well  ex- 
posed. 

In  hospitals  the  removal  of  the  dressing  should 
be  done  in  a  separate  room  suited  to  this  particu- 
lar purpose,  whenever  the  condition  of  the  patient 
will  allow  him  to  be  transferred.  In  the  surgical 
ward  of  a  hospital  it  is  convenient  to  keep 
patients  that  require  dressings  separate  from 
the  others.  For  instance,  a  laparotomy  case 
should  not,  as  a  rule,  be  contiguous  to  a  case 
of  subcutaneous  fracture.  It  is  always  advisable 
to  attend  aseptic  cases  before  dressing  or  treat- 
ing suppurating  and  infected  ones. 


238  SURGICAL   ASEPSIS. 

When  the  writer  enters  the  suroical  ward  of 
the  hospital  the  first  act  of  the  nurse  in  charge 
is  to  prepare  boiHng  water  for  the  small  ward 
sterilizer.  While  attention  is  being  given  to 
patients  not  suffering  from  wounds  such  as  frac- 
tures, dislocations,  inflammatory  processes,  etc., 
preparations  are  being  made  for  the  renewal  of 
the  dressings  of  patients  who  cannot  be  trans- 
ferred to  the  separate  room.  The  instruments 
are  sterilized  at  the  same  time,  and  are  taken 
directly  from  the  apparatus  after  the  assistants, 
the  nurses,  and  the  writer  have  disinfected  their 
hands  according  to  the  principles  of  prophylactic 
disinfection.  After  use  the  instruments  are 
replaced  in  the  sterilizer.  While  an  assistant 
finishes  the  bandaging  the  writer  again  disin- 
fects his  hands  precisely  as  before,  and  the 
house- staff  are  required  to  do  likewise.  The 
instruments  are  again  taken  from  the  sterilizer, 
and  another  patient's  dressings  are  renewed  in 
the  same  manner. 

There  is  no  excuse  for  not  observing  the  same 
precautions  in  dispensary  and  in  private  practice. 
In  the  surgical  department  of  a  dispensary  the 
work  is  greatly  facilitated  by  separating  patients 
with  traumatisms  from  the  other  patients,  and  by 
dressinpf  the  former  after  the  latter  have  been 
attended  to.  After  a  dressing  has  been  removed 
the  instruments  used  for  its  renewal  are  put  for 


TECHNIQUE    OF  AN  ASEPTIC   OPERATION.      239 

two  minutes  into  boiling  soda-solution.  They 
are  then  taken  out  by  long,  sterilized  forceps  and 
put  into  the  basin  containing  the  aseptic  instru- 
ments in  sterilized  water.  This  basin  was  termed 
by  the  writer  "the  sanctum,"  in  order  to  guard 
against  mistakes  on  the  part  of  young  assistants 
and  nurses  in  the  different  designations  of  the 
aseptic  arrangements.  Whatever  instrument  has 
been  handled  must  be  boiled  in  the  sterilizer 
before  it  is  regarded  worthy  of  a  place  among 
the  instruments  in  this  aseptic  basin.  After  each 
re-dressing  the  hands  must  again  be  disinfected 
before  making  another  new  dressino-. 

At  first  the  above-mentioned  manipulations 
appear  to  be  cumbrous,  but  one  soon  becomes 
thoroughly  familiarized  with  them  through  habit. 


XIII.  TECHNIQUE  OF  AN  ASEPTIC  OPERA- 
TION. 

Whenever  time  allows,  the  following  series  of 
preparations  should  precede  all  important  opera- 
tions. One  or  more  baths  should  be  given  the 
patient  to  cleanse  thoroughly  the  surface  of  the 
whole  body.  Before  this,  the  patient's  urine 
should  be  examined  wdth  the  cjreatest  care  as 
soon  as  he  has  entered  the  hospital.  Only  soft 
and  easily-digested  food  should  be  allowed.  If 
the  bowels  have  not  been  evacuated,  a  laxative 


240  SURGICAL   ASEPSIS. 

must  be  administered.  Where  ulcers  and  ecze- 
mas are  present,  their  cure  should  be  effected,  if 
possible,  before  the  operation  is  performed.  In 
operations  upon  the  stomach,  the  intestines,  or  the 
vagina,  irrigations,  especially  enemas  or  douches, 
should  first  be  employed ;  for  preliminary  prep- 
arations on  other  parts  of  the  body  see  Section 
IV.,  on  Prophylactic  Disinfection.  In  urgent 
cases,  such  as  a  herniotomy  for  an  incarcerated 
gut,  such  preparations,  unhappily,  cannot  be 
made,  as  life  may  depend  upon  immediate  ope- 
rative interference ;  but  the  well-trained  aseptic 
operator  knows  how  to  adapt  himself  to  the  emer- 
gency, and  will  even  then,  by  rigidly  carrying 
out  the  principles  of  prophylactic  disinfection, 
especially  upon  the  field  of  operation,  maintain 
his  position  as  master  of  the  situation. 

The  surgeon  should  be  surrounded  by  a  staff 
of  well-trained  assistants  and  nurses,  to  each  of 
whom  his  or  her  place  must  be  assigned,  and 
whose  duties  are  well  outlined,  so  that  every  one 
does  exactly  what  is  ordered,  and  nothing  else. 
The  surgeon  should  make  it  a  special  rule  to 
prepare  all  the  material  necessary  beforehand, 
so  that  during  operation  everything  is  ready  and 
within  easy  reach.  The  running  around  of 
assistants  or  nurses  while  an  operation  is  going 
on  is  always  a  symptom  of  defective  knowledge 
or  valuation  of  surgical  asepsis.      The  surgeon 


SURGICAL     ASEPSIS. 


Plate  VII 


SURGICAL    ASEPSIS. 


Plate  VIII. 


^      lO 


TECHNIQUE    OF  AN  ASEPTIC   OPERATION.      24I 

should  personally  superintend  the  necessary 
preparations,  and  should  not  depend  too  much 
upon  other  persons.  Therefore  his  presence  at 
least  three-quarters  of  an  hour  before  the  opera- 
tion is  advisable. 

It  is  always  important  to  give  the  nurses  a 
thorough  understanding  of  the  enormous  respon- 
sibility resting  upon  them,  even  if  they  merely 
handle  a  piece  of  gauze  or  a  needle.  They, 
as  well  as  the  surgeon  himself,  should  bathe  daily, 
and  they  should  always  wear  freshly-washed 
suits. 

In  the  operating-room  there  should  be  kept 
readv  for  the  suro^eon  and  his  staff,  as  well  as  for 
the  nurses,  a  number  of  sterilized  suits  (PL  VIII., 
Figs.  I,  2,  3)  to  cover  the  entire  body.  These  suits 
should  be  of  some  light  material,  twilled  muslin 
and  light  linen  being  useful  for  the  purpose. 
The  sleeves  of  the  coats  should  cover  the  upper 
arm  only.  During  operation  the  surgeon's  suit 
may  happen  to  come  into  contact  with  the  cloth- 
ing of  an  assistant :  if  the  latter  also  wears  a 
sterilized  coat,  no  mischief  will  be  done  by  such 
contact ;  if,  however,  the  assistant's  coat  is  not 
sterilized,  pathogenic  microbes  may  settle  upon 
the  surgeon's  coat,  and  by  further  contact  con- 
tamination of  the  field  of  operation  may  be  pro- 
duced. In  private  practice,  if  such  suits  are  not 
available,  sterilized  shirts  may  be  substituted. 

16 


242  SURGICAL   ASEPSIS. 

The  head  also  should  be  covered  with  a  cap, 
as  In  bending  over  the  field  of  operation  it  often 
happens  that  the  heads  of  the  surgeon  and  his 
assistant  come  into  contact.  Such  caps  are  best 
sewed  to  the  operating-suit. 

Long  beards  are  a  disadvantage,  and,  if  their 
possessors  do  not  feel  like  sacrificing  them  on 
the  altar  of  asepsis,  must  be  protected. 

Before  the  operating-suit  is  put  on,  coat,  waist- 
coat, collar,  and  cuffs  should  be  removed,  and 
care  should  be  taken  that  the  hands  do  not  after- 
ward come  into  contact  with  the  clothing. 

The  time  required  for  preparations  nowadays 
generally  exceeds  that  necessary  for  the  opera- 
tion, and  it  is  true  that  the  urgent  necessity  of 
observing  the  many  minute  details  demanded  by 
asepsis  is  its  most  disagreeable  feature,  but  at 
the  same  time  is  the  conditio  sine  qua  non  for 
success. 

Aseptic  virtues  arise  more  from  a  touch  of 
character  than  from  a  capacity  learned  by  edu- 
cation. There  are  some  surgeons  born  aseptic, 
so  to  say,  and  others  who  will  never  be  able  to 
become  thoroughly  aseptic,  no  matter  how  often 
they  are  admonished. 

Operative  skill,  desirable  as  it  is,  at  the  pres- 
ent time  does  not  possess  half  the  degree  of 
importance  attaching  to  this  particular  feature 
of  character ;    and  it  will  often  be  noticed  that 


TECHNIQUE    OF  AN-  ASEPTIC   OPERA TION.      243 

the  operations  of  less  skilful  surgeons,  performed 
with  a  comparatively  small  degree  of  dexterity, 
are  more  successful  in  their  final  results,  pro- 
vided they  are  thoroughly  aseptic,  than  the 
operations  of  surgeons  less  scrupulous  in  their 
preparations,  even  though  the  technical  work  be 
performed  with  the  greatest  possible  elegance. 

About  one  hour  before  the  operation  is  per- 
formed, there  are  put  into  the  steam  sterilizer 
in  the  operating-room  the  gauze,  the  dressing 
materials,  etc.,  which,  after  being  sterilized,  are 
placed  in  metallic  boxes  standing  on  glass 
tables  near  the  operating-table,  within  easy  reach 
of  the  surofeon  and  his  assistants.  When  the 
materials  are  not  in  use  they  may  be  covered  with 
pieces  of  sterilized  linen. 

In  a  box  or  a  basin  there  should  be  kept  ready 
a  large  quantity  of  different-sized  gauze  mops, 
which  at  the  beginning  of  the  operation  are 
handed  to  the  surgeon  or  to  his  assistant  by 
the  attendinof  nurse. 

Shortly  before  anaesthesia  is  begun,  the  instru- 
ments are  selected  and  put  into  the  boiling  soda- 
solution.  Upon  removing  the  instruments  from 
the  solution  they  are  deposited  in  sterilized  dishes 
or  bowls,  or,  if  such  vessels  cannot  be  obtained, 
upon  sterilized  towels  placed  upon  a  medium- 
sized  glass  table  (Fig.  45),  easily  accessible.  Cat- 
gut or  silk  sutures  and  the  materials  for  drainage 


244  SURGICAL   ASEPSIS. 

should  also  be  close  by,  so  that  they  can  be 
handed  to  the  surgeon  by  the  assistant  in  charge 
of  the  instruments.  If  the  writer  s  metal  box 
for  silk  or  catgut  (Fig.  42)  is  used,  it  must  be 
surrounded  by  gauze  after  being  taken  from  the 
sterilizer.  On  another  table,  standing  less  near 
than  that  for  the  gauze  mops,  but  within  reach 
of  the  nurse,  are  placed  several  basins,  bowls,  or 
plates.  One  of  the  vessels  should  contain  the 
necessary  bandages,  another  the  gauze  for  the 
dressings,  and  a  third  the  protective  material, 
such  as  moss  or  cotton. 

Before  the  patient  is  brought  into  the  operat- 
ing-room— the  surgeon  and  his  staff  having  dis-- 
infected  their  hands  according  to  the  principles 
described  in  Section  IV.,  and  having  put  on  their 
operating-suits — each  assistant  has  his  place  as- 
signed and  his  duties  oudined.  To  one  assistant, 
who  stands  opposite  the  operating  surgeon,  is 
assigned  the  duties  of  sponging,  holding  the 
tenacula,  and  rendering  such  other  assistance  as 
may  be  required.  Another  assistant  is  detailed 
to  pass  the  instruments.  This  assistant  keeps  an 
accurate  list  of  all  the  instruments  needed  in  the 
various  operations  ;  this  list  must  be  consulted  be- 
fore putting  the  instruments  into  the  sterilizer,  to 
be  sure  that  everything  required  is  well  prepared. 
If  the  latter  assistant  does  not  possess  the  un- 
limited confidence  of  the  surgeon,  he  had  better 


TECHNIQUE    OF  AN  ASEPTIC   OPERATION.      245 

be  dispensed  with,  the  instruments  being  placed 
within  the  surgeon's  reach.  A  third,  the  most 
rehable  assistant,  is  charged  with  the  anaesthesia. 

After  the  assistants  and  the  nurses  have  been 
inspected  by  the  surgeon  and  their  aseptic  con- 
dition has  been  approved,  they  are  ordered  to 
the  positions  to  be  occupied  during  the  operation. 
A  table  or  a  chair  is  then  placed  about  twenty 
inches  behind  (to  the  right  of)  each  assistant 
and  nurse.  These  tables  hold  large  wash-basins 
containing  hot  bichloride  solution  (i  :  1000-5000), 
which  is  to  be  used  under  the  circumstances 
previously  alluded  to   (p.  243). 

No  conversation  is  to  be  permitted  about  the 
operating-table,  so  that  the  surgeon's  commands 
may  be  audible  to  all  and  be  promptly  obeyed. 

Should  an  instrument,  a  towel,  a  bandage,  or  a 
dressing  drop  to  the  floor,  an  attendant  especially 
assigned  to  this  duty,  and  who  is  regarded  as 
non-aseptic,  must  at  once  take  up  the  article  and 
either  throw  it  into  a  pail  or  tie  about  it  a  piece 
of  bandage  or  a  ribbon  to  indicate  its  useless- 
ness  for  the  operation.  Instruments  or  dressings 
thus  vitiated  may  again  be  rendered  sterile,  how- 
ever, by  replacing  them  in  the  sterilizer. 

Nothing  should  be  required  of  the  ntcrses 
except  to  hand  to  the  surgeon  the  gauze  mops, 
the  towels,  and  the  dressing  materials,  and  to 
attend  to  the  solutions,  etc.    They  should  under- 


246  SURGICAL   ASEPSIS. 

Stand  that  after  once  being-  disinfected  they  must 
not  touch  anything  that  may  be  contaminated. 
If  a  nurse  or  an  attendant  has  to  perform  any 
non-aseptic  manipulations — such,  for  instance, 
as  holding  the  patient  in  a  certain  position  or 
putting  away  a  pus-basin — he  should  not  do  any 
work  which  may  bring  him  into  contact  with  the 
wound  except  he  has  worn  sterilized  gloves  dur- 
ing such  manipulations  and  has  taken  them  off 
thereafter. 

It  is  preferable  to  have  an  extra  room  in  a  hos- 
pital for  ancBsthetizing  patients  (PL  X.,  Fig.  2), 
that  they  may  not  witness  the  necessary  prelim- 
inary arrangements  for  the  operation.  If  such  a 
room  cannot  be  had,  the  patient  should  be  anaes- 
thetized without  delay  on  the  operating-table,  as 
it  is  cruel  and  apt  to  excite  the  patient  if  he  lies 
conscious  on  the  table  where  he  can  see  the 
instruments,  etc.  Shortly  before  the  anaesthetic 
is  administered  the  patient  should  be  surround- 
ed with  a  large  sterilized  linen  bed-sheet  or  be 
put  into  the  sterilized  operating-suit  devised  by 
the  writer  (PL  VII.  ;  PL  VIII.,  Fig.  4).  The  writer 
has  found  it  useful  to  have  these  sterilized  linen 
suits,  of  different  sizes,  ready  for  all  operations 
on  the  body  or  on  the  extremities  of  the  patient. 
The  suits  are  made  somewhat  similar  to  a  strait- 
jacket,  openings  being  left  in  the  middle  of  the 
abdominal  part,  in  the  part  over  the  chest,  and 


SURGICAL     ASEPSIS. 


Plate  IX. 


SURCxICAL    ASEPSIS. 


Plate  X. 


TECHNIQUE    OF  AN  ASEPTIC   OPERATION       247 

at  both  wrists  ;  the  latter  openings  are  to  permit 
feehng  of  the  pulse.  Wherever  an  incision  has  to 
be  made  there  may  be  cut  into  the  linen  jacket 
a  hole  which  may  be  sewed  up  after  each  use  of 
the  dress.  In  private  practice  a  sheet,  if  prop- 
erly applied,  would  answer  the  same  purpose. 

As  soon  as  the  patient  is  partly  anaesthetized, 
he  is  brought  into  the  operating-room.  The  ope- 
rating-table is  prepared  in  the  manner  described 
in  Section  V.  Prophylactic  disinfection  is  carried 
out  once  more  in  the  most  rigorous  manner,  after 
the  field  of  operation  has  been  exposed  and  sur- 
rounded by  sterilized  cloths  taken  directly  from 
the  sterilizer.  The  surgeon's  hands,  as  well  as 
the  operating  instruments  and  the  aseptic  mate- 
rial, must  be  prevented  from  coming  into  contact 
with  the  undisinfected  portions  of  the  patient's 
body  in  the  neighborhood  of  the  field  of  opera- 
tion. The  instruments  in  the  mean  time  may  be 
laid  upon  sterilized  trays  or  towels,  thus  pro- 
moting the  work  if  speed  is  required. 

In  operating  upon  an  extremity,  if  the  writer's 
jacket  is  not  applied,  both  the  extremities  should 
be  enveloped  in  sterilized  cloths,  otherwise  in- 
voluntary movements  of  the  patient  might  bring 
the  undisinfected  limb  into  contact  with  the  dis- 
infected one. 

During  operation  the  surgeon,  his  assistants, 
and    the    nurses    should   wear   linen    coats   (see 


248  SURGICAL   ASEPSIS. 

jpage  241 ).  The  condition  of  the  coats  is  of  the 
greatest  importance,  as  nothing  except  the  hand 
is  apt  to  take  up  so  much  infectious  material 
as  they  do.  They  should  therefore  be  sterilized 
thoroughly  in  steam  before  the  operation.  The 
heads  of  the  surgeon,  the  assistants,  and  the 
nurses  should  be  covered  with  linen  caps. 

Instriunents  can  easily  be  sterilized  under  the 
direct  control  of  the  operating  surgeon,  their 
disinfection  requiring  but  a  few  minutes;  but 
the  materials  which  must  be  sterilized  in  steam 
require  a  longer  time,  especially  catgut  and  gauze 
mops,  which  demand  a  considerable  length  of 
time  for  their  sterilization,  but  which  may  be  pre- 
served in  an  aseptic  state  after  they  have  once 
been  sterilized.  Reliable  druo^orists  should  be 
induced  to  keep  such  materials  in  stock,  so  that 
they  may  be  obtained  at  any  moment.  But 
owing  to  the  grave  responsibility  associated  with 
sterilization,  it  seems  preferable  to  the  writer  that 
the  trouble  should  be  taken  of  personally  disin- 
fecting the  materials. 

Towels  as  well  as  gauze  may  be  sterilized  a 
few  days  before  the  operation,  and  they  may 
then  be  preserved  in  proper  metallic  boxes  until 
required.  This  preparation  in  advance  is  a  great 
convenience,  as  by  it  much  time  can  be  saved,  but 
greater  security  is  guaranteed  if  sterilization  is 
done  immediately  before  the  operation. 


TECHNIQUE    OF  AN  ASEPTIC   OPERATION.       249 

Better  to  illustrate  the  views  of  the  writer,  it 
is  advisable  to  describe  in  detail  the  procedures 
before  and  during  an  operation.  Supposing  a 
radical  operation  for  inguinal  hernia  is  to  be  per- 
formed on  a  Tuesday  at  lo  a.  m.  :  The  patient  is 
given  a  warm  bath  on  the  previous  Sunday,  spe- 
cial care  being  taken  with  the  inguinal  region, 
which  is  scrubbed  and  shaved.  The  scrotum 
and  the  inguinal  region  being  also  thoroughly 
scrubbed  and  shaved,  the  patient  is  put  in  a  bed 
supphed  with  fresh  Hnen  sheets,  etc.  A  poultice 
of  green  soap  (see  p.  96)  is  then  applied  to  the 
field  of  operation,  and  after  having  remained 
there  for  three  hours  is  scrubbed  away  again, 
thus  removing  as  much  epithelium  as  possible. 
The  w^hole  area  is'  then  protected  with  com- 
presses or  with  a  towel  saturated  with  bichloride 
solution  (i  :  1000).  On  Monday  the  same  pro- 
cedures are  repeated. 

At  7  A.  M.  on  Tuesday,  the  day  of  operation,  a 
small  cup  of  coffee  and  a  cracker  may  be  allowed 
the  patient.  If  more  nourishment  is  taken,  vom- 
iting may  set  in,  which  is  apt  to  interfere  seriously 
with  the  aseptic  state  of  the  field  of  operation. 
About  8.30  A.  M.  there  are  put  into  the  steam- 
sterilizer  in  the  operating-room  the  gauze,  the 
dressing  materials,  etc.,  which,  after  being  ster- 
ilized, are  placed  in  metallic  boxes  standing  on 
glass  tables  near  the  operating-table,  within  easy 


250  SURGICAL  ASEPSIS. 

reach  of  the  surofeon  and  his  assistants.  Dishes 
or  bowls,  silk,  catgut,  material  for  gauze  mops, 
etc.  in  sufficient  quantity  are  kept  ready,  the 
instrument  list  should  be  consulted  once  more, 
and  the  operating-table  must  be  prepared.  The 
surgeon,  his  staff,  and  the  nurses  are  thoroughly 
disinfected  and  are  assigned  their  duties.  After 
everything  is  prepared  and  the  patient  has  been 
put  into  his  jacket  the  anaesthesia  is  begun. 
When  the  patient  is  half  anaesthetized  he  is 
brought  upon  the  operating-table. 

The  field  of  operation  may  now  be  exposed, 
and  the  inguinal  region,  as  well  as  the  scrotum, 
the  abdomen,  and  both  thighs,  be  scrubbed  again 
energetically  with  soap  and  warm  water.  The 
whole  area  is  then  dried  with  towels  and  is  again 
washed  with  alcohol  and  the  bichloride  solution. 

Sterilized  towels  to  surround  the  field  of  ope- 
ration are  then  taken  from  the  sterilizer  and 
pinned  together  with  sterilized  safety-pins.  The 
penis  should  also  be  surrounded  with  sterilized 
gauze.  In  female  patients  the  pubis  should  be 
shaved  and  the  vagina  be  kept  packed  with  ster- 
ilized orauze. 

After  the  incision,  at  least  three  inches  in 
lenorth,  has  been  made  over  the  hernial  tumor, 
the  various  structures  are  carefully  divided.  Be- 
fore the  sac  is  reached  each  bleeding  vessel  is 
caught  with  forceps  and  is  at  once  ligated.     It  is 


TECHNIQUE    OF  AN  ASEPTIC   OPERATION.      2$  I 

quite  customary  to  wipe  a  bleeding  surface  with 
a  sponge  in  a  forcible  manner.  This  is  wrong.  If 
a  sponge  is  gently  passed  along  the  line  of  incis- 
ion for  one  second  and  is  then  withdrawn,  the 
purpose  is  accomplished  and  the  operating  sur- 
geon is  least  hindered.  Considerable  capillary 
hemorrhage  must  be  checked  by  compressing 
the  surface  with  pieces  of  gauze  for  a  greater 
length  of  time.  The  sac  is  then  pinched  up  by 
a  pair  of  mouse-tooth  forceps,  and  into  it  a  small 
opening  is  made  through  which  a  grooved  direc- 
tor can  be  introduced.  Further  division  under 
the  guidance  of  the  director  is  now  made,  the 
surfaces  being  so  separated  by  tenacula  that  a 
thorough  inspection  may  be  made. 

The  sac  is  nov/  dissected  out  carefully  and  is 
cautiously  separated  from  the  cord.  After  wip- 
ing the  blood-coagula  from  the  intestine  the  lat- 
ter is  replaced  in  the  abdominal  cavity.  The  sac 
is  then  drawn  down,  and  is  either  removed  after 
being  ligated  with  catgut  or  silk  or  treated  in 
one  of  the  numerous  methods  prescribed.  While 
the  wound  is  covered  and  compressed  with  ster- 
ilized gauze  the  vicinity  of  the  field  of  operation 
is  thoroughly  cleansed,  the  blood  especially  be- 
inor  removed ;  it  is  advisable  to  use  moist  eauze 
mops  for  this  purpose,  and  after  having  dried  this 
area  the  gauze  is  removed  from  the  wound.  If 
the  slightest  hemorrhage  be   noticed,  additional 


252  SURGICAL   ASEPSIS. 

ligatures  must  be  applied.  The  wound-surfaces 
may  be  united  only  after  they  have  become  per- 
fectly dry.  Where  coaptation  is  imperfect  there 
must  be  used  buried  sutures,  which  only  excep- 
tionally will  be  needed  after  the  operation  de- 
scribed. After  the  field  of  operation  has  been 
cleansed  again  it  is  covered  with  sterilized  gauze, 
which  should  exert  more  or  less  pressure. 

Excellent  immobilization  is  obtained  if  a  large 
piece  of  sterilized  moss-board  surround  the  abdo- 
men and  the  thighs.  By  splitting  the  board  in  the 
middle  of  its  lower  portion  (Fig.  34),  which  is 
to  lie  above  the  perineal  region,  splints  for  both 
thighs  can  be  secured,  as  shown  on  page  122. 
In  restless  patients  the  employment  of  such  im- 
mobilization is  of  great  importance  ;  it  generally 
answers  the  purpose  so  perfectly  that  plaster  of 
Paris  may  be  dispensed  with. 

If  no  disturbance  is  observed  after  the  opera- 
tion, the  dressing  may  remain  for  at  least  one 
week ;  it  should  then  be  removed.  A  part  of 
the  sutures  also  should  be  removed  if  silk  has 
been  used.  A  fresh  light  dressing  should  be  ap- 
plied, and  be  allowed  to  remain  for  another  five 
or  six  days,  or  until  perfect  recovery  is  assured. 

The  preparations  described  above  should  be 
made  before  any  other  operation,  be  it  a  lapar- 
otomy, a  resection  of  a  shoulder,  or  an  amputa- 
tion of  the  mammae.     Some  surgeons  think  that 


ASEPTIC  INJECTION.  253 

they  are  bound  to  make  such  preparations  when 
they  intend  to  perform  a  laparotomy,  but  do  not 
observe  any  such  precautions  in  so-called  "minor 
surgery."  There  is  no  mmor  surgery.  The  same 
principles  stand  for  the  operation  of  an  ingrow- 
ing toe-nail  as  for  an  abdominal  section.  It  is 
not  so  infrequent  that  death  has  followed  even 
the  simplest  surgical  operations  when  they  were 
performed  with  a  disregard  of  aseptic  rules. 


XIV.  ASEPTIC  INJECTION. 

A  hypodermic  syringe  is  a  surgical  instrument, 
and  it  must  be  sterilized  upon  the  same  princi- 
ples as  other  constituents  of  the  surgical  arma- 
mentarium, lest  it  may  prove  a  source  of  serious 
infection. 

Before  making  an  injection  the  skin  of  the 
patient  as  well  as  the  hands  of  the  surgeon 
should  be  rendered  clean,  exactly  as  when  pre- 
paring for  any  other  operation,  and  the  fluid  used 
must  be  sterilized.  Syringe  and  needles  should 
also  be  sterilized.  Omission  of  these  precau- 
tions has  frequently  caused  tubercular,  specific, 
and  anthrax  infection,  and  even  death  by  sepsis. 

Morphine  injections  have  often  been  reported 
as  the  cause  of  infection  in  consequence  of  the 
use  of  a  hypodermic  syringe  which  had  pre- 
viously   been    employed    on    an    erysipelatous 


254  SURGICAL   ASEPSIS. 

patient.  Frankel  recently  published  two  cases 
of  fatal  spreading  gangrene  following  subcu- 
taneous injections. 

The  busy  practitioner  may  probably  claim  that 
innumerable  injections  made  without  the  slightest 
aseptic  precautions  have  not  been  followed  by 
evil  consequences.  This  claim  must  be  taken 
cum  grano  salis.  Small  abscesses  following  such 
injections  do  not  generally  come  under  the  ob- 
servation of  the  practitioner,  mainly  because  the 
patient  does  not  call  upon  him  for  the  treatment 
of  a  'Mittle  boil,"  which  he  deems  amenable  to 
home  remedies. 

Infection,  however,  occurs  not  so  often  as 
would  be  expected  when  one  considers  the  great 
number  of  injections  made  in  disregard  of  asep- 
tic precautions.  This  is  probably  due  to  the  rapid 
absorption  of  fluids  taking  place  in  the  cellular 
tissue,  the  microbes  there  finding  no  conditions 
favorable  for  their  development.  But  this  fortu- 
nate circumstance  does  not  excuse  carelessness. 

So  far  as  fluids  for  injections  are  concerned, 
only  bacteriological  investigations  can  demon- 
strate their  more  or  less  aseptic  character. 

The  drugs  most  commonly  used  for  injection 
are  morphine,  atropine,  cocaine,  ergotine,  pilocar- 
pine, ether,  camphor,  iodine,  alcohol,  carbolic  acid, 
mercurial  preparations,  and  solutions  or  emul- 
sions of  iodoform.     With  the  exception  of  mor- 


ASEPTIC  INJECTION.  255 

phine,  atropine,  ergotine,  pilocarpine,  and  cocaine, 
all  these  drugs  possess  a  considerable  amount 
of  antiseptic  power  which  is  apt  to  prevent  the 
development  and  multiplication  of  micro-organ- 
isms, so  that  they  are  generally  sterile. 

Schimmelbusch's  repeated  examinations  of  a 
morphine  solution  (i  per  cent.,  as  generally  em- 
ployed) showed  the  presence  of  from  two  hun- 
dred to  three  hundred  microbes  to  each  cubic 
centimetre.  It  is  therefore  advisable  to  add 
some  antiseptic  agent,  such  as  carbolic  acid  or 
bichloride,  to  such  solutions  as  morphine,  atro- 
pine, ergotine,  pilocarpine,  and  cocaine.  Bacteri- 
ological investigations  prove  that  the  addition  of 
two  drops  of  pure  carbolic  acid  to  the  ounce  of 
a  sterile  injection-fluid  containing  such  drugs 
suffices  to  keep  the  solution  sterile  for  a  consid- 
erable length  of  time.  Alcohol,  ether,  bichloride, 
and  carbolic  acid  do  not  require  sterilization. 

Few  of  the  drugs  named  above  are  of  surgical 
importance  so  far  as  their  utilization  for  injec- 
tions is  concerned,  and,  with  the  exception  of 
iodoform,  they  are  used  only  to  a  limited  extent 
for  curative  injections  into  diseased  organs. 

Regarding  the  frequent  employment  of  iodo- 
form for  injection,  the  writer  deems  it  necessary 
to  point  out  its  indications  and  effects,  particu- 
larly as  bacteriological  investigations  as  well  as 
clinical  experience  have  proven  its  great  thera- 


256  SURGICAL   ASEPSIS. 

peutic  value.     (Compare  Section  III.,  p.  83,  and 
Section  XL,  p.  207.) 

If  iodoform  is  dissolved  in  ether,  no  steriliza- 
tion is  required,  but  if  an  emulsion  is  made  of 
glycerin  or  oil,  sterilization  should  not  be  omitted. 
The  emulsion  will  then  generally  remain  sterile 
for  many  weeks.  The  most  acceptable  method 
of  sterilizmg  an  emulsion  of  iodoform  is  to  fill  a 
bottle  and  to  expose  it  to  the  steam  of  a  ster- 
ilizer for  about  an  hour.  The  bottle  should  not 
be  closed  by  a  stopper,  lest  pure  iodine  be  set 
free.  If  a  steam  apparatus  is  not  available,  the 
oil  and  the  glass  bottle  may  be  boiled  sepa- 
rately, and  after  the  completion  of  this  process 
the  iodoform  may  be  added.  It  has  been  sug- 
gested that  iodoform  powder  be  first  washed  with 
a  solution  of  bichloride  to  render  it  sterile. 

The  addition  of  mucilage  is  not  advisable,  on 
account  of  the  great  difficulty  of  thoroughly  ster- 
ilizing it.  Good  emulsions,  easily  kept  sterile, 
can  be  made  with  glycerin,  and  oil  of  sweet 
almond  will  dissolve  5  per  cent,  of  iodoform. 
The  disadvantage  of  an  emulsion  or  an  oily 
solution  is  that  it  cannot  be  forced  through  a 
hypodermic  needle.  Ethereal  solutions  do  not 
present  this  obstacle  to  their  use. 

Since  it  is  a  recognized  fact  that  at  least  one 
person  out  of  every  seven  dies  of  some  form  of 
tuberculosis,  the  great  importance  of  antituber- 


ASEPTIC  INJECTION.  257 

cular  agents  is  evident.  Iodoform  undoubtedly 
possesses  antitubercular  properties  to  a  marked 
degree.  Bruns,  Nauwerck,  and  Stubenrauch 
found,  after  injecting  iodoform  glycerin  into 
tubercular  abscesses  (commonly  called  ''  cold 
abscesses"),  that  the  tubercular  structures  were 
substituted  by  firm,  normal,  vascular  tissue.  The 
tubercular  area  underwent  fatty  degeneration 
and  necrosis ;  later  on  cicatrization  took  place. 
These  experiments  prove  that  iodoform  pos- 
sesses decided  tuberculocidal  influence. 

It  is  still  an  open  question  whether  the  destruc- 
tion of  the  bacilli  is  exclusively  due  to  the  pri- 
mary effect  of  iodoform  upon  tuberculous  tissue, 
as  maintained  by  Troje  and  Tangl  in  consequence 
of  their  interesting  experiments,  or  whether 
indirectly  the  alteration  of  this  tissue,  which  is  a 
favorable  soil  for  the  bacilli,  is  the  cause  of  their 
destruction.  Practically,  however,  it  makes  no 
difference  whether  this  tuberculocidal  influence 
Is   a   direct  or  an  indirect  one. 

In  tubercular  abscesses,  such  as  are  often  found 
In  joints,  for  instance,  iodoform  must  be  used  in 
comparatively  large  quantities.  Long  before 
the  Investigations  reported  above  verified  this 
necessity,  clinical  experience  showed  clearly  that 
when  small  quantities  of  iodoform  were  Injected 
Into  tubercular  abscesses  cultures  of  the  bacillus 
tuberculosis    were    generally    obtained,    but   the 

17 


258  SURGICAL   ASEFS*IS. 

same  evidence  could  never  be  furnished  when 
large  quantities  were  used. 

Stubenrauch  endeavored  to  inoculate  animals 
with  tuberculous  tissue  obtained  from  lodoform- 
ized  tubercular  abscesses,  but  In  no  case  did  he 
succeed  In  producing  tuberculosis  when  he  used 
large  quantities  of  the  drug. 

In  the  treatment  of  tuberculous  joints,  psoas 
abscesses,  tuberculosis  peritonei,  etc.  Iodoform 
oil  Is  especially  recommended  (compare  p.  262). 
If  the  joint  contains  no  fluid,  the  Injections  will 
have  to  be  made  at  different  points  each  time,  a 
needle  of  large  calibre  being  required.  If  the 
different  foci  contain  large  masses  of  cheesy 
material,  or  If  necrotic  bone  be  present,  a  cure 
cannot  be  effected  by  this  process,  but  when 
only  fluid,  such  as  pus,  Is  present  the  chances  of 
success  with  Iodoform  Injections  are  more  favor- 
able. That  the  Iodoform  may  come  In  contact 
with  all  surfaces  and  sinuses  of  the  cavity,  the 
latter  must  first  be  emptied. 

The  antltubercular  influence  of  Iodoform  Is 
intensified  if  hypercemia  in  the  tubercular  area  Is 
produced,  the  iodoform  injections  then  being 
made  after  the  principles  described  below.  Hy- 
percemia seems  to  produce  conditions  unfavor- 
able for  the  development  of  tuberculosis.  Rok- 
itansky  has  called  attention  to  the  fact  that  con- 
gestions of  the  lungs  in   persons  suffering  from 


ASEPTIC  INJECTION.  259 

heart  disease  or  from  kyphosis  are  apt  to  render 
them  immune  against  tuberculosis  pulmonum. 
Even  in  patients  who,  while  suffering  from  well- 
marked  tuberculosis,  acquired  other  pathological 
conditions  which  caused  congestion  of  the  lungs, 
perfect  recovery  from  their  tuberculosis  was  ob- 
served. The  value  of  artificial  hypercEmia  for 
therapeutic  purposes  is  therefore  obvious.  Hy- 
peraemia  can  best  be  produced  by  making  a 
slight  constriction  above  the  tubercular  focus. 
Bier  advises  surroundinor  the  tubercular  extrem- 
ity  with  linen  bandages  below  the  diseased  area 
and  applying  an  Esmarch  bandage  above  it, 
so  as  to  cause  venous  stasis  in  the  periph- 
ery. As  the  rubber  bandage  produces  consid- 
erable pressure,  it  is  advisable  to  put  a  piece  of 
cotton  or  linen  beneath  it.  Furthermore,  it  is 
advisable  to  change  the  dressings  at  least  twice 
a  day.  The  ends  of  the  rubber  bandage  should 
be  fastened  by  forceps  instead  of  by  making  a 
knot,  lest  the  latter  cause  excessive  compression. 
Bier's  method,  however,  should  be  recommended, 
for  obvious  reasons,  only  for  hospital  practice. 

For  making  injections  the  writer  devised  an 
irrigation  trocar  (Fig.  56)  which  materially  differs 
in  construction  from  other  trocars,  in  that  it  admits 
the  introduction  of  a  second  canula  after  the  stylet 
has  been  withdrawn.  This  second  canula  con- 
sists of  a  double-barrelled  tube.      Through  the 


26o  SURGICAL   ASEPSIS. 

smaller  of  these  tubes,  which  may  be  connected 
with  an  irrigator,  a  sterilized  liquid  can  be  in- 
jected. The  larger  tube  permits  the  escape  of 
those  solid  particles  which  generally  may  be  ex- 
pected in  the  pus  of  such  cavities  as  those  al- 


FiG.  56. — Beck's  irrigation  trocar. 

luded  to  above.  Iodoform  In  glycerin  or  in  oil 
can  then  be  injected  through  the  larger  tube 
either  by  an  irrigator  or  by  a  piston  syringe. 
The  advantages  of  this  instrument  are  that  it 
can  easily  be  rendered  sterile  in  a  boiling  soda- 
solution,  and  that  the  force  of  the  irrigation  stream 
dislodges  solid  fragments  and  carries  them  off 
with  the  recurrent  flow.  At  the  same  time  the 
force  of  the  water  can  easily  be  regulated. 

The  trocar  should  be  introduced  at  a  distance 
from  the  most  prominent  point  of  the  swelling, 
the  better  to  conduct  it  through  healthy  skin- 
tissue.  The  skin  should  be  drawn  to  one  side, 
so  that  after  withdrawal  of  the  trocar  the  wound- 
canal  of  the  deep  tissues  is  not  situated  imme- 
diately beneath  the  wound  in  the  skin.  The 
opening  in  the  skin  must  be  sealed  with  iodo- 
form collodion  after  the  operation  is  completed. 


ASEPTIC  INJECTION.  26 1 

The  average  dose  employed  for  these  Injec- 
tions should  be  between  4  drachms  and  i  ounce, 
and  their  strength  should  be  lo  per  cent.  Injec- 
tions may  be  made  at  intervals  of  one  or  two 
weeks  until  evidences  of  satisfactory  repair  are 
obtained  or  until  three  or  four  injections  show 
no  result,  in  which  event  operative  interference 
should  no  longer  be  delayed  (compare  p.  264). 

Immobilization  is  necessary  so  long  as  the 
patient  is  under  treatment.  In  children  moss 
splints  (Fig.  34)  are  most  useful ;  in  adults  fenes- 
trated dressings  of  plaster  of  Paris  are  advisable. 
In  spondylitic  abscesses  orthopaedic  appliances 
are  indispensable  for  support. 

The  results  obtained  by  many  authors,  notably 
Konig,  Krause,  and  Senn,  who  report  cures  in  50 
per  cent,  of  their  cases,  and  those  in  the  writer's 
practice  within  the  last  few  years,  in  thus  treating 
occluded  tubercular  abscesses,  are  so  very  en- 
couraging that  it  seems  no  less  than  a  crime  to 
perform  resection  of  a  joint  except  after  iodo- 
formization  has  failed. 

If  it  is  borne  in  mind  that  iodoform  has  un- 
doubtedly cured  tuberculosis,  and  that  even  sim- 
ple opening  of  the  abdomen^ — that  is,  exposure 
to  atmosphere  and  light — is  apt  to  produce  such 
metamorphosis  in  a  tubercular  nodule  as  to  trans- 

^  "  Tubercular  and  Suppurative  Peritonitis,"  New  York  Medical  Jojirtial, 
April  21,  1894. 


262  SURGICAL  ASEPSIS. 

form  It  into  innocent  scar-tissue,  we  may  be 
justified  in  hoping  that  the  near  future  may 
bring  about  such  improved  methods  as  will  effect 
a  perfect  cure  of  this  most  dreadful  disease. 

As  shown  before,  iodoform  in  oil  or  in  glycerin 
proves  ineffectual  as  a  parenchymatous  injec- 
tion into  solid  tumors  or  into  elands  or  o-oitre ; 
nor  will  it  serve  for  circumvenous  injection  in 
hemorrhoids,  varices,  or  varicocele,  as  it  is  im- 
possible to  force  a  sufficient  quantity  through 
a  small  hypodermic  needle.  An  ethereal  solu- 
tion is  the  only  available  form  in  such  cases,  as  it 
\vill  readily  pass  through  the  finest  needle. 

The  disadvantageous  features  of  ethereal  solu- 
tions are — first,  intense  pain  for  a  minute  or  two 
after  injection  ;  second,  the  likelihood  of  gan- 
grene of  the  overlying  tissues  in  consequence 
of  over-distention  from  volatilization  of  the  ether. 

The  evil  effects  from  injections  of  ethereal 
solutions  are  due  not  to  the  iodoform,  but  to  the 
ether.  It  cannot  be  denied  that  an  ounce  of 
ether  injected  into  a  cavity,  whether  or  not  the 
ether  be  mixed  with  iodoform,  is  fraught  with 
danger.  Gangrene  caused  by  over-distention 
from  the  volatilization  of  ether  can  be  avoided 
by  injecting  deeply  into  the  tissues. 

Ethereal  injections  into  solid  tumors  may,  as 
a  rule,  be  made  every  second  or  third  day.  If 
symptoms  of   inflammation  follow  the  injection, 


ASEPTIC  INJECTION.  263 

fomentations  of  acetate  of  aluminum  should  be 
applied  until  the  swelling  subsides.  When  but 
one  hypodermic  syringeful  is  employed  iodoform 
intoxication  need  never  be  feared. 

A  fatal  termination  to  a  case  wherein  the 
ethereal  solution  of  iodoform  was  employed  is 
reported  by  Barvis.^  The  patient,  a  man  twenty- 
four  years  old,  had  a  cold  abscess  in  the  left 
thoracic  region.  After  evacuating  the  pus  from 
the  cavity  Barvis  injected  over  2  ounces  of  a  sat- 
urated ethereal  solution  of  iodoform.  Collapse 
immediately  followed,  proved  fatal,  and  was  attrib- 
uted by  the  author  to  the  action  of  the  iodoform. 
The  speedily  fatal  result,  however,  makes  it  ap- 
pear as  if  some  of  the  fluid  entered  the  pleural 
cavity,  where  the  rapidly  evaporating  ether  was 
quickly  absorbed.  Had  an  innocent  combination, 
such  as  oil,  for  instance,  been  combined  with  the 
iodoform  used  in  this  case,  evil  results  would 
probably  not  have  supervened. 

It  may  be  stated  in  this  connection  that  suppu- 
ration following  the  use  of  oleaginous  mixtures 
of  iodoform  has  never  occurred  in  the  writer's 
experience.  Olive  oil,  being  the  mildest  and 
most  innocuous  constituent,  should  always  be 
employed  when  large  quantities  of  the  emulsion 
are  required.     Glycerin  is  unobjectionable  only 

^  "  Du  Traitement  des  Abces  Froids  :  Intoxication   lodoformique  Mor- 
telle,"  Archives  de  Medecine  et  de  Pharniacie,  Tome  xvi.,  No.  8,  1S90. 


264  SURGICAL   ASEPSIS. 

when  used  In  quantities  not  exceeding  an  ounce 
in  adults  and  comparatively  less  in  children. 

Absorption  is  more  apt  to  take  place  from 
joints  than  from  so-called  ''cold  abscesses," 
their  membranes  generally  absorbing  slowly. 
The  symptoms  of  glycerin-intoxication,  which 
occurs  much  more  easily  in  children  than  in 
adults,  consist  of  a  slight  elevation  of  the  tem- 
perature and  an  acceleration  of  the  pulse.  In 
the  urine  red  blood- corpuscles  are  always  found, 
and  in  severe  forms  cylinders  are  detected,  this 
indicating  great  irritation  of  the  kidneys.  In 
spite  of  these  disadvantages,  the  writer  could 
not  be  induced  to  give  up  the  combination  of 
iodoform  and  glycerin,  especially  in  the  treat- 
ment of  tuberculosis,  as  the  slight  inflammatory 
reaction  following  the  Injection  of  iodoform-glyc- 
erln  seems  to  intensify  the  influence  of  the  Iodo- 
form upon  the  tubercular  tissues. 

Enlarged  glands  of  the  neck  generally  yield 
to  iodoform-ether  injections.  This  treatment, 
however,  is  usually  inefficacious  In  glands  whose 
centres  have  undergone  caseous  degeneration. 
In  such  cases,  if  three  or  four  Injections,  made  at 
Intervals  of  two  or  three  days,  prove  unsuccess- 
ful, extirpation  is  indicated.  It  is  evident  that 
by  following  these  principles  a  diagnosis  ex ptvari- 
tibus  et  nocentibus  can  be  made  ;  In  other  words, 
that  if,  after  three  or  four  injections,  the  gland 


ASEPTIC  INJECTION.  265 

has  not  decreased  In  size,  caseous  degeneration 
of  the  centre  of  the  gland  may  be  assumed,  and 
extirpation  should  then  be  delayed  no  longer. 

The  same  course  is  advisable  in  joints,  which 
should  be  resected  if  no  improvement  is  obtained 
after  three  or  four  injections  of  iodoform. 

In  reference  to  the  treatment  of  the  compara- 
tively rare  form  of  tuberculosis  of  the  perito- 
neum (compare  pp.  85  and  261)  the  following 
conclusions  may  be  offered  : 

1.  The  injection  of  an  iodoform  mixture  (i  :  10) 
into  the  peritoneal  cavity  exerts  a  specific  anti- 
tubercular  action. 

2,  The  diagnosis  of  tubercular  peritonitis  in 
the  early  stages  being  possible  only  in  excep- 
tional cases  (for  instance,  in  the  serous  form)» 
and  injection  of  iodoform  being  useful  in  other 
peritonitic  processes,  it  is  particularly  indicated 
in  all  doubtful  cases. 

Iodoform  in  powder  or  In  solution  is  indicated 
also  after  laparotomy  w^ienever  it  is  desirable 
to  limit  the  discharges  ;  furthermore,  it  appears 
that  absorption  of  the  products  of  the  microbes 
becomes  less  virulent  in  its  results  by  the  co- 
absorption  of  Iodoform. 

Ordinary  hypodermic  sy^dnges  can  be  sterilized 
only  with  great  difficulty,  the  inaccessibility  of 
the  piston  proving  a  decided  obstacle.  Robert 
Koch  therefore    discards  the  piston    altogether, 


266 


SURGICAL  ASEPSrS. 


substituting  a  rubber  bulb  to  drive  out  the  con- 
tents of  the  syringe.  But  by  the  adoption  of 
this  bulb  one  of  the  most  valuable  dia^rnostic 
qualities  of  the  syringe — namely,  aspiration — is 
almost  entirely  lost.  Further,  the  Koch  syringe 
cannot  be  used  for  the  injection  of  emulsions. 
These  are  points  sufficient  to  prevent  the  adop- 
tion of  Koch's  syringe  in  general  practice.  The 
most  convenient  syringes  are  the  asbestos  syringes 
(Fig.  57,  a  and  b)  ;  but  all  syringes  the  pistons 


Fig.  57. — a,  Overlach's  syringe;  b,  Meyer's  syringe. 


of  which  consist  entirely  of  asbestos  work  excel- 
lendy  for  a  certain  length  of  time,  but  soon  prove 
ineffectual,  as  the  asbestos  easily  gets  out  of 
order.     It  is  evident  from  the  principles  empha- 


ASEPTIC  INJECTION. 


267 


sized  in  this  work  that  preference  should  be  given 
to  such  syringes  as  can  be  boiled  in  a  soda-solu- 
tion. It  is  a  rather  unfortunate  fact  that  ordinary- 
hypodermic  syringes  will  not  stand  the  solution 
without  injury.  Much,  however,  can  be  done  by 
drawing  boiling  water  through  them,  w^hich  is 
usually  not  injurious. 

The  best  aseptic  syringe  know^i  to  the  writer 
is  the  one  devised  by  Schmidt  of  Berlin  (Fig.  58). 
It  is  made  entirely  of  metal,  so  that 
boiling  does  not  impair  its  useful- 
ness. The  cylinder  of  the  syringe, 
as  well  as  the  hollow  piston,  is  made 
of  nickel  alloy.  The  elastic  piston 
is  tightly  fitted  to  the  walls  of  the 
cylinder  and  glides  freely  through 
it  after  being  anointed  with  glyc- 
erin. The  ingenious  hypodermic 
syringe  devised  by  Hotzen  of  New 
York  is  constructed  upon  similar 
principles,  the  only  drawback  being 
that  a  piece  of  cork  must  be  con- 
nected with  the  piston.  The  needles  can  easily 
be  rendered  sterile  by  being  boiled  in  a  soda- 
solution.  If  they  are  made  of  platinum,  they  can 
also  be  sterilized  in  the  flame  of  an  alcohol 
lamp. 


Fig.  58— Schmidt's 
aseptic  syringe. 


268  SURGICAL  ASEPSIS. 

XV.  ANAESTHESIA. 

The  entire  civilized  world  owes  an  untold  debt 
of  gratitude  to  America  for  the  benefit  of  many 
important  inventions  and  discoveries.  However 
great  the  best  of  these  may  be,  none  can  equal 
in  importance  to  suffering  humanity  the  discovery 
in  1846,  by  Dr.  W.  T.  G.  Morton  of  Boston,  of 
the  anaesthetic  properties  of  sulphuric  ether. 
This  discovery  marks  an  entirely  new  era  in 
surgery.  Before  that  time  painless  operations 
were  impossible  ;  thenceforth  anaesthesia  became 
a  tangible  reality  throughout  the  whole  world. 

The  merit  of  Morton's  discovery  is  not  at  all 
impaired  by  the  fact  that  Dr.  James  Y.  Simpson 
of  Edinburgh  a  year  later  discovered  chloroform, 
the  great  rival  of  ether.  Much  time  has  since 
been  wasted  in  discussing  the  relative  merits  and 
demerits,  advantages  and  disadvantages,  of  these 
two  agents.  A  satisfactory  setdement  of  the 
question  is  yet  to  be  hoped  for.  It  is  not  aston- 
ishing that  drugs  capable  of  depriving  a  person 
of  consciousness  to  the  degree  of  rendering  him 
insensible  to  pain  are  not  free  from  danger. 
Nevertheless,  the  proper  administration  of  either 
drug,  and  careful  watching,  will  reduce  the 
danger  to  a  minimum.  The  writer,  if  interro- 
gated  by  the  patient  as  to  the  possible  dangers 
of  anaesthesia,  compares   it  with  a  sea-trip,  the 


ANESTHESIA.  269 

dangers  of  which  are  known,  although  ordinarily 
not  feared. 

It  could  hardly  be  that  the  administration  of 
either  of  such  powerful  drugs  as  ether  and  chloro- 
form should  not  produce  some  changes  in  the 
various  organs  of  the  body  (especially  in  the 
brain,  heart,  lungs,  and  kidneys),  at  least  during 
the  time  of  administration.  That  there  are  such 
changes  is  evidenced  by  the  fact  that  in  300 
cases  of  ether  anaesthesia  occurring  in  the  writer's 
practice,  albumen  was  found  twenty-seven  times 
after  the  anaesthesia,  while  before  it  not  a  trace  of 
albumen  could  be  detected.     The  lenorth  of  time 

o 

the  ether  remains  in  the  system  can  be  inferred 
by  the  odor  ex  ore,  which  sometimes  can  be 
noticed  so  late  as  three  days  after  operation.  In 
urine  passed  after  an  ether  anaesthesia  a  more 
or  less  decided  smell  of  ether  can  always  be 
detected. 

We  are  necessarily  quite  In  the  dark  as  regards 
the  poisonous  action  of  anaesthetics,  as  most 
experiments  that  might  reveal  the  cause  cannot 
be  made  upon  living  subjects. 

For  a  long  time  chloroform  was  enthusiastically 
held  in  favor  in  Europe,  but  recently  the  agita- 
tions of  French  and  German  sureeons  have 
caused  it  to  be  supplanted  gradually  by  ether. 
The  views  of  suroreons  reo^ardine  the  relative 
value  of  chloroform  and  ether  vary  widely,  but 


270  SURGICAL   ASEPSIS. 

there  can  be  no  doubt  that  each  of  these  drues 
has  its  advantaores  and  disadvantages. 

Ether  should  not  be  administered  in  cases  of 
atheroma  of  the  arteries,  nor  in  renal  or  pul- 
monary disease.  In  kidney  diseases  it  is  apt  to 
cause  suppression  of  the  urine.  In  diseases  of 
the  respiratory  organs,  such  as  asthma,  emphy- 
sema, bronchitis,  etc.,  the  vapor  of  the  ether 
irritates  the  bronchi.  In  operations  on  the  face 
or  in  the  mouth,  in  which  cases  it  is  impossible 
to  keep  the  patient  constantly  anaesthetized, 
ether  is  also  contraindicated. 

There  are  patients  who,  although  apparently 
healthy,  have  a  sensitive  mucous  membrane  of 
the  respiratory  tract,  so  that  they  show  a  high 
rate  of  respiration  in  ether  anaesthesia.  They 
also  cough  even  in  deep  anaesthesia.  In  such 
cases  chloroform  should  be  substituted. 

In  diseases  of  the  heart  the  administration  of 
chloroform  is  extremely  dangerous ;  therefore 
ether  should  be  given  in  such  cases. 

The  choice  of  an  anaesthetic  and  its  correct 
administration  are  of  as  great  importance  from 
the  aseptic  standpoint  as  they  are  on  the  score 
of  anaesthesia  proper.  Indeed,  the  aseptic  con- 
dition of  the  patient  may  be  impaired  seriously 
should  there  be  required  the  manipulations  neces- 
sary for  resuscitation  from  asphyxia.  No  sur- 
geon should  ever  neglect  to  admonish  a  patient 


ANESTHESIA.  2/ 1 

regarding  abstinence  from  food  the  morning  the 
operation  is  to  be  performed  under  anaesthesia. 
But  these  admonitions,  if  not  seriously  made,  are 
often  disregarded  in  private  practice,  as  is  shown 
by  the  prodigious  quantities  of  partly-digested 
food  sometimes  vomited  by  private  patients 
during  and  after  anaesthesia.  The  danger  of 
omitting  this  precaution  is  multiform ;  but  pri- 
marily it  is  manifestly  a  risk  to  the  aseptic  con- 
dition of  the  wound,  especially  when  the  wound 
is  in  the  head,  the  neck,  or  the  chest.  It  is  im- 
portant, therefore,  that  the  mouth  be  kept  turned 
from  the  side  on  which  the  wound  is  situated,  lest 
the  vomit  contaminate  the  wound  and  thwart  all 
aseptic  endeavors.  It  is  evident  that  the  very 
first  effort  at  vomiting  must  be  met  by  prompt 
action  directed  especially  to  prevent  wound- 
contamination. 

The  condition  of  the  inhaler  merits  close 
attention.  It  may  readily  become  infected  in 
operations  upon  septic,  diphtheritic,  and  erysip- 
elatous cases.  The  frame  of  a  chloroform-inhaler 
should  consist  of  metal,  preferably  wire,  which 
can  be  rendered  sterile  by  boiling,  and  should  be 
so  arranged  that  it  can  be  covered  with  a  few 
layers  of  sterilized  gauze.  For  private  practice 
the  writer  has  devised  a  mask  made  of  two  wire 
frames  which  can  be  folded  together  like  a  note- 
book  and  be  carried  in  the  pocket. 


2J2  SURGICAL  ASEPSIS. 

For  ether  anaesthesia  any  one  of  the  many 
cones  or  inhalers  may  be  used,  or  a  simple 
apparatus  may  be  improvised  by  folding  into  a 
cone  a  sterilized  towel  supported  by  thick  paper 
or  pasteboard,  and  fastening  it  with  safety-pins. 
The  writer  has  a  predilection  for  the  "  Clover 
inhaler,"  which  has  the  great  advantage  that  the 
anaesthetizer,  by  measuring  the  amount  of  ether 
inhaled,  is  able  to  regulate  its  administration. 
This  inhaler  also  excels  by  its  rapidity  in  pro- 
ducing anaesthesia. 

Before  and  durinor  ether  or  chloroform  anaes- 
thesia  the  following  rules  should  be  observed: 

1.  The  urine  should  always  be  analyzed,  espe- 
cially before  the  administration  of  ether,  and  the 
heart  and  lungs  must  be  examined  carefully. 

2.  Foreign  bodies,  such  as  false  teeth,  tobacco, 
etc.,  must  be  taken  from  the  mouth. 

3.  The  clothing  must  be  loosened  to  prevent 
even  the  slightest  constriction  of  the  circulation 
or  the  respiration. 

4.  The  patient  should  assume  the  dorsal  decu- 
bitus, as  syncope  may  occur  in  the  sitting  posture. 
His  head  should  rest  low,  on  a  small  pillow,  so 
that  it  is  in  line  with  the  body. 

5.  Before  the  chloroform-inhaler  is  applied 
the  lips  and  the  face  should  be  anointed  with 
vaseline  as  a  preventive  of  irritation  and  excori- 
ation. 


ANESTHESIA.  273 

6.  The  patient  should  be  instructed  to  close 
his  eyes  and  to  take  deep,  full,  and  regular  res- 
pirations. His  attention  should  also  be  called  to 
the  fact  that  the  first  inhalations,  although  dis- 
agreeable, do  not  subject  him  to  danger.  If  he 
shows  symptoms  of  excitement,  he  should  be 
calmed  and  encouraged  by  kind  words.  Ner- 
vous patients  sometimes  struggle  considerably 
after  they  have  made  but  one  inspiration.  This 
occurs  especially  under  ether.  In  such  cases  it  is 
well  to  drop  the  mask  and  to  explain  that  further 
proceedings  will  be  impossible  until  the  patient 
remains  quiet.  Such  statements  should  be  made 
in  the  kindest  manner,  otherwise  the  patient 
becomes  indignant  over  the  lack  of  sympathy  on 
the  part  of  the  anaesthetizer,  and  it  is  difficult 
then  to  calm  his  excitement. 

7.  Chloroform  must  be  administered,  slowly, 
and  mixed  always  with  a  sufficient  quantity  of 
air.  If  ether  is  given,  this  precaution  is  unneces- 
sary and  may  delay  anaesthesia  and  waste  the 
ether,  but  in  case  of  cyanosis  breaths  of  pure  air 
should  be  allowed  until  the  cyanosis  has  disap- 
peared. 

8.  The  surgeon  should  not  begin  an  operation 
until  the  patient  is  fully  under  the  influence  of 
the  anaesthetic,  or  ''in  surgical  anaesthesia,"  which 
is  indicated  by  paralysis  of  the  palpebral  reflex 
and  by  relaxation  of  the  voluntary  muscles. 

18 


274 


SURGICAL   ASEPSIS. 


9.  Good  ventilation  should  be  had  in  the  ope- 


ratino-room. 


10.  Whenever  possible,  operations  by  gas-, 
candle-,  or  lamp-light  should  be  avoided.  Aside 
from  their  insufficiency,  they  are  a  serious  men- 
ace, on  account  of  their  liability  to  cause  an  ex- 
plosion by  igniting  the  vapors  of  ether. 

1 1 .  The  safest  way  of  administering  chloro- 
form is  to  let  it  continuously  fall  upon  the  inhaler 
from  a  dropping-bottle.  A  Braatz  inhaler  (Fig. 
59)  is  a  very  useful  apparatus  for  the  purpose. 

12.  The  pupils  should  be  watched 
to  ascertain  if  they  are  dilated  or  if 
they  respond  to  light.  Dilatation  or 
their  failure  to  respond  to  light  must 
be  viewed  as  a  sign  of  approaching 
danger.  Repeated  testing  of  the 
corneal  reflex,  however,  is  not  wise, 
as  a  much  more  reliable  index  for  full 
anaesthesia  is  represented  by  the  rate 

Fig.  59.— The    g^i-^^i  character  of  the  respiration. 

Braatz  inhaler.  r^         r   ^  ^  1 

13.  Careiul  and  permanent  control 
of  the  pulse  and  respiration  is  of  the  greatest 
importance.  In  fact,  the  respiration  needs  more 
attention  than  the  pulse.  Quickening  of  the  res- 
piration, as  well  as  weak  pulse  or  respiration, 
may  denote  that  too  much  of  the  anaesthetic  has 
been  administered.  Loud  stertor  in  chloroform 
anaesthesia  is  also  an  alarming  symptom,  as  it  in- 


ANESTHESIA.  2/5 

dicates  epiglottidean  closure  of  the  larynx.  If  any 
such  disturbance  is  observed,  the  anaesthetic  must 
be  discontinued  instantly.  If  falling  back  of  the 
tongue  has  occluded  the  larynx,  the  lower  jaw 
must  be  pushed  forward  and  the  tongue  be  drawn 
out  with  forceps.  At  the  same  time  the  thorax 
should  be  elevated,  so  that  the  head  and  neck 
may  fall  back.  By  this  manipulation  the  point 
of  support  of  the  tongue  is  changed  from  the 
posterior  pharyngeal  wall  to  the  palate,  by  which 
procedure  the  space  between  the  pharynx  and 
the  root  of  the  tongue  becomes  free.  Mucus, 
which  is  apt  to  accumulate  in  the  mouth  or  the 
throat,  especially  under  ether  anaesthesia,  must 
be  removed  from  time  to  time.  This  removal  is 
best  effected  by  thrusting  into  the  pharynx  a 
sponge  attached  to  a  holder,  while  the  jaws  are 
kept  separate  with  a  maxillary  separator  (Fig. 
6i). 

14.  For  at  least  five  hours  before  the  opera- 
tion the  patient  should  eat  no  solid  food,  nor 
should  liquid  food  be  allowed  later  than  three 
hours  before  the  operation.  Some  brandy  and 
cracked  ice  may  be  administered  shortly  before 
the  operation,  or,  if  the  padent  is  weak,  hot 
brandy  or  claret  may  be  injected  into  the  rectum. 

Habitual  drinkers  and  very  nervous  individuals 
should  receive  a  hypodermatic  injection  of  mor- 
phine (^   to  ^  grain)  twenty  to  thirty  minutes 


2/6  SURGICAL  ASEPSIS. 

before  the  anaesthesia  is  commenced.  Morphine 
injection  should  also  be  performed  before  opera- 
tions on  the  face,  the  mouth,  the  pharynx,  or  the 
nose,  in  which  cases  the  operation  should  be  be- 
gun the  instant  perfect  anaesthesia  is  established. 

All  patients  are  liable  to  accident  during  anaes- 
thesia, despite  the  most  careful  precautions. 
Vomited  material  may  enter  the  larynx,  or  the 
tongue  may  fall  back  and  press  the  epiglottis 
against  the  entrance  to  the  larynx.  Most  of 
these  accidents  are  attributed  to  cardiac  par- 
alysis. Accidents  may,  however,  be  due  to  an 
overdose  of  the  anaesthetic,  as  well  as  to  a  spe- 
cial pathological  condition  of  the  heart,  the  cha- 
racteristic signs  and  symptoms  of  which  condition 
were  not  recognized  by  the  surgeon  :  this  condi- 
tion is  vaguely  termed  an  ''idiosyncrasy,"  and  its 
victims  may  appear  to  be  in  perfect  health. 

Many  deaths  during  or  after  operations,  from 
what  is  vaguely  termed  "  shock,"  are  doubtless 
closely  related  to  the  effects  of  anaesthetics.  If 
all  such  cases  could  be  analyzed  minutely,  and 
if  all  accidents  of  this  kind  were  published,  the 
death-rate  would  be  swelled  considerably.  It  is 
quite  human  that  a  surgeon  is  much  more  prone 
to  attribute  a  fatal  result  to  "shock"  than  to 
some  omission  or  to  the  effects  or  after-effects 
of  an  anaesthetic. 

If  any  of  the  above-described  symptoms  are 


ANAESTHESIA.  277 

threatened,  the  administration  of  the  anaesthetic 
should  at  once  be  discontinued,  and  it  should 
only  be  continued  slightly  if  the  pulse  remains 
weak. 

In  cases  where  the  functions  of  the  organs 
of  the  chest  are  much  impaired  by  compression 
through  a  serous  or  purulent  effusion — In  the 
thorax,  for  instance — only  a  few  drops  of  chloro- 
form should  be  poured  upon  the  inhaler.  The 
same  caution  should  be  observed  in  cases  of 
sepsis  and  of  burns  of  the  third  degree,  where 
through  the  absorption  of  toxines,  which  are 
severe  heart-venoms,  the  heart's  action  is  so 
much  depressed.  Patients  afflicted  with  such 
conditions  are,  however,  not  very  sensitive  to 
pain,  as  the  toxines  exert  an  anaesthetic  Influence. 

A  limited  a^icesthesia  frequently  leaves  an  im- 
pression only,  and  not  a  clear  perception,  of  all 
the  surgical  procedures,  and  frequently  It  Is  the 
nervous  dread  of  these  procedures,  and  not 
the  physical  pain  itself,  which  terrifies  the  most 
courageous  patients.  The  odor  alone  of  an 
anaesthetic  will  sometimes  give  the  patient  the 
agreeable  impression  of  growing,  or  of  being, 
insensible  to  pain. 

If  respiration  becomes  impaired^  operations 
may  properly  be  finished  without  the  further 
administration  of  the  anaesthetic.  It  is  less  cruel 
to  trouble  the  patient  and  to  save  his  life  than  to 


2/8  SURGICAL  ASEPSIS. 

eive  him  the  so-called  benefit  of  full  anaesthesia 
and  to  risk  his  life  under  the  pretext  of  humanity. 
The  forceps  with  which  the  tongue  is  drawn 
forward  merits  some  special  attention.  When- 
ever the  symptoms  of  respiratory  impediment 
appear  and  do  not  yield  prompdy,  the  assist- 
ant in  charge  of  the  anaesthetic  should  place  his 
fingers  behind  the  angles  of  the  lower  jaw  and 
force  the  jaw  forward.  If  breathing  does  not 
then  promptly  become  normal,  the  tongue  must 
be  seized  with  sterilized  forceps  and  be  pulled 

forward.  The  jaws  of  the 
forceps  should  be  built 
strongly,  and  the  handles 
be  provided  with  a  catch, 

Fig.  6o. — Beck's  tongue-forceps.  ,  , 

SO  that  the  mstrument  can- 
not slip  from  the  tongue.  The  writer  uses  an 
instrument  made  especially  for  this  purpose  (Fig. 
60).  In  construction  it  is  similar  to  a  Pean 
forceps,  the  surfaces  of  its  strongly-built  blades 
being  very  broad,  so  as  to  catch  a  considerable 
portion  of  the  tongue.  An  interspace,  to  leave 
room  for  the  non-compressed  portion  of  the 
tongue,  is  provided  between  the  catching  portion 
and  the  joint. 

The  introduction  of  the  forceps  is  frequently 
difficult,  as  the  teeth  may  be  pressed  firmly  to- 
gether, in  which  case  the  Roser-Konig  mouth- 
forceps  is  of  great  value,  as  it  rapidly  separates 


vSURGICAL    ASEPSIS. 


Plate  XI. 


ANESTHESIA. 


279 


the  maxillae.  The  writer  has  devised  several 
modifications  of  this  useful  instrument,  the  most 
important  of  which  is  the  establishment  of 
grooves  in  the  triangular  mouth-piece  of  the 
forceps  (Fig.  61,  b).  After  this  modified  sepa- 
rator (Fig.  61,  a)  is  introduced  it  is  turned  side- 
wise,  and  by  forcing  the  grooves  into  the  teeth 


Fig.  61. — Beck's  modified  maxilla-separator. 

the  instrument  will  be  prevented  from  falling  out. 
The  removal  of  mucus  Is  thus  rendered  easy. 

If  ordinary  means  do  not  suffice  to  restore 
breathing,  resort  must  be  had  to  the  induction 
of  artificial  respi^^ation.  The  writer  has  found 
it  useful  to  combine  artificial  respiration  with 
stimulation  of  the  heart  and  lowerinor  of  the 
head,  as  illustrated  by  Plate  XI.  After  having 
placed  the  patient  in  a  position  similar  to  that  of 
Trendelenburg,  an  assistant  grasps  the  arms  at 
the  elbows,  carries  them  outward  and  upward 
above  the  head,  and  brings  them  back  to  the 
anterior  surface  of  the  thorax.  This  movement 
should  be  performed  in  a  rhythmical  manner  and 


28o  SURGICAL   ASEPSIS. 

about  eighteen  times  per  minute.  At  the  same 
time  another  assistant  thrusts  his  fingers  against 
the  apex  of  the  heart,  as  if  employing  a  species 
of  massage.  While  these  manipulations  are 
being  made  camphorated  oil  and  tincture  of 
strophanthus  may  be  injected  hypodermatically. 
Many  other  valuable  methods  exist,  but  it  is  best 
to  stick  to  a  few,  so  as  to  become  thoroughly 
familiarized  with  them  and  to  be  able  to  carry 
them  out  well.  It  appears  to  the  writer  that  the 
procedures  above  described  are  the  most  reliable 
and  are  ordinarily  sufficient. 

If  consideration  is  ofiven  to  the  fact  that  the 
essential  difference  between  ether  and  chloroform 
is  that  the  first  produces  an  irritant  action  while 
the  second  exercises  a  depressant  one,  it  becomes 
clear  why  chloroform  is  the  more  dangerous  of 
the  two  drugs  diu^ing  operation. 

Experience  has  demonstrated  that  the  great 
majority  of  deaths  under  chloroform  anaesthesia 
occur  at  the  preliminary  stage,  even  before  the 
surgeon  can  use  the  knife.  What  is  the  legal 
responsibility  of  an  accident  of  this  kind  every 
physician  well  knows. 

The  dangers  of  ether  anaesthesia  usually  set  in 
during  its  after-effect.  Not  a  few  persons  with- 
out the  slightest  evidence  of  kidney  disease  die 
shortly  after  an  insignificant  surgical  operation 
in  which  ether  has  been  administered.     Diffuse 


ANESTHESIA.  28 1 

nephritis  being  found,  the  fatal  outcome  is  ex- 
plained. But  this  is  not  the  only  remote  danger 
of  ether.  CEdema  pulmonum,  broncho-pneu- 
monia, and  collapse,  according  to  a  number  of 
reliable  surgeons,  have  frequently  followed  the 
administration  of  ether.  CEdema  pulmonum 
and  collapse  may  take  place  even  several  hours 
after  the  operation,  and  are  then  generally  not 
attributed  to  the  anaesthetic.  Such  occurrences 
usually  not  being  considered  in  statistics,  it  is 
natural  that  erroneous  conclusions  are  drawn  in 
reference  to  the  "safety"  of  ether.  On  the  con- 
trary, as  in  all  diseases  of  the  respiratory  tract 
even  the  most  enthusiastic  friends  of  ether  use 
chloroform  anaesthesia,  it  is  just  the  most  un- 
favorable cases  that  are  reserved  for  the  chloro- 
form. Autopsies  are  made  only  exceptionally, 
therefore  an  anatomical  explanation  for  the  fatal 
end  is  rarely  found.  Autopsies  in  cases  of  sud- 
den death  after  chloroform  generally  give  no 
explanation.  It  is  supposed  that  death  from 
chloroform  is  produced  by  fatty  degeneration 
of  the  heart  and  by  an  overloading  of  the 
blood  with  carbonic  .  acid.  Some  physicians 
maintain  that  death  would  be  caused  by  an  abun- 
dant formation  of  nitrogen. 

As  shown  previously,  many  deaths  have  re- 
sulted from  the  after-effects  of  ether.  An  immi- 
nent peril  being  always  much  more  feared  than  a 


282  SURGICAL   ASEPSIS. 

remote  one,  it  seems  to  be  natural  that  the  dan- 
gers of  chloroform  appear  the  more  formidable 
to  the  practitioner,  who  dreads  a  fatal  collapse  in 
the  operating-room  more  than  he  does  one  in  the 
sick-bed — that  is,  after  some  time  has  elapsed 
following  the  operation  ;  therefore  he  gives  pref- 
erence to  ether. 

As  it  stands  to-day,  there  is  no  ancEsthesia  with- 
out a  possible  risk.  The  freedom  of  some  physi- 
cians, especially  beginners,  in  the  administration 
of  anaesthetics  in  the  treatment  of  triflinor  in- 
juries  and  for  diagnostic  purposes  is  explainable 
only  on  the  ground  of  their  ignorance  of  the 
danger.  Experienced  physicians  are  usually 
more  careful,  and  avoid  anaesthesia  whenever 
they  can,  their  experience  and  diagnostic  talent 
enabling  them  frequently  to  determine  patholog- 
ical conditions  by  exercising  patience  and  by 
using  combined  scientific  methods,  thus  not  ex- 
posing their  patients  to  any  risk  in  examination. 
For  trifling  injuries  an  anaesthetic  should  be 
avoided  whenever  possible,  and  local  anaesthe- 
sia be  substituted. 

Local  ancesthesia  is  obtained  either  by  the 
application  of  cold  or  by  the  use  of  hydro- 
chlorate  of  cocaine.  For  minor  operations  cold 
can  best  be  obtained  by  spraying  either  sulphuric 
ether  or  a  combination  of  ether,  chloroform,  and 
menthol  over  the  surface  with  an  atomizer   for 


ANESTHESIA.  283 

about  two  minutes.  The  integument,  after  at 
first  becoming  reddened,  assumes  a  white  color, 
and  finally  becomes  parchment-like  and  insensi- 
ble. The  structures  beneath  the  skin  are  not 
influenced  by  this  procedure. 

Hydrochlorate  of  cocaine,  for  the  discovery  of 
the  local  anaesthetizing  power  of  which  sur- 
gery will  for  ever  be  indebted  to  Carl  Roller 
of  New  York,  is  invaluable  in  operations  upon 
the  mucous  membranes,  as  those  of  the  eye, 
mouth,  nose,  larynx,  vagina,  uterus,  etc.  It  can 
be  applied  by  a  swab  of  cotton  in  a  solution  of 
from  4  to  20  per  cent.  In  operations  upon  other 
parts  of  the  body  it  may  be  applied  hypodermati- 
cally  in  a  solution  of  from  i  to  2  per  cent.  An  Es- 
march  bandage  will  prevent  cocaine-intoxication 
and  at  the  same  time  will  increase  the  anaesthetiz- 
ing power  of  the  cocaine.  The  injection,  being  of 
itself  painful,  should  always  be  preceded  by  the 
application  of  an  ether  spray.  A  i  per  cent, 
solution  is  generally  strong  enough  for  hypoder- 
matic purposes.  Great  care  should  be  taken  to 
inject  at  different  points  around  the  proposed  line 
of  incision.  A  small  quantity  should  be  injected 
into  the  cellular  tissues  and  into  the  deeper 
layers,  and  a  larger  quantity,  by  slowly  withdraw- 
ing the  needle,  should  be  forced  directly  into  the 
skin,  so  that  the  epidermis  is  gradually  raised 
aloncr  the  line  of  the  intended  incision. 


284  SURGICAL  ASEPSIS. 

Operations  done  under  local  anaesthesia  should 
be  performed  with  special  rapidity.  The  majority 
of  manipulations  can  just  as  well  be  done  rapidly 
as  slowly;  however,  if  speed  can  be  exercised  only 
at  the  expense  of  thoroughness,  rapid  manipula- 
tion would  do  more  harm  than  good,  and  would 
then  be  one  of  the  most  dangerous,  instead  of 
one  of  the  best,  attributes  of  a  surgeon. 


XVI.  ASEPSIS   IN   PRIVATE   PRACTICE. 

The  prevalent  though  erroneous  supposition 
among  busy  practitioners  that  strict  asepsis  can 
be  carried  out  only  in  hospitals  proves  a  serious 
obstacle  to  its  principles  being  always  observed 
in  private  practice.  While  in  former  years  the 
general  practitioner  was  envied  by  the  hospital 
surofeon  because  he  need  not  fear  infectious  dis- 
eases  being  transferred  to  his  patient  in  a  private 
residence,  the  general  practitioner  now  envies 
the  hospital  surgeon  because  a  well-equipped 
aseptic  hospital  offers  superior  advantages  for 
his  surgical  cases. 

As  shown  in  the  previous  sections  of  this 
work,  the  main  difference  between  asepsis  in  a 
hospital  and  asepsis  in  private  practice  exists 
only  in  the  greater  amount  of  care  and  atten- 
tion to  aseptic  principles  required  by  the  latter. 
These    principles    are    so  simple  that   it   seems 


ASEPSIS  IN  PRIVATE   PRACTICE.  285 

Strange  that  the  majority  of  the  profession  does 
not  recognize  the  feasibiHty  with  which  asepsis 
may  be  carried  out  in  private  practice. 

The  main  difficuhy  in  convincing  general  prac- 
titioners seems  to  be  that,  not  being  sufficiently 
familiar  with  the  fundamental  principles  of  asep- 
sis, they  dread  the  commission  of  errors  which 
might  thwart  the  object  in  view.  They  are  more 
familiar  with  "antiseptic  precautions,"  and  there- 
fore declare  that  they  "place  more  reliance  upon 
antisepsis  than  upon  asepsis,  as  the  splendid  re- 
sults obtained  under  antiseptic  precautions  are 
sufficient  proof  of  their  efficacy." 

But  on  a  close  examination  of  the  so-called 
"antisepsis"  of  such  colleagues  there  is  encoun- 
tered great  superficiality.  Many  deem  the  mere 
dipping  of  the  fingers  into  a  bichloride  solution 
just  before  operation  as  an  adequate  Insurance 
against  infection,  being  regardless  of  the  condition 
of  their  hands,  which  only  a  few  minutes  before 
may  have  been  In  a  carcinomatous  rectum.  In- 
struments taken  from  a  pocket-case  saturated 
with  sweat  are  put  into  a  carbolic-acid  solution 
to  whose  percentage  no  importance  is  attached. 
Furthermore,  the  carbolic  acid  frequently  is  undis- 
solved, lying  in  full  strength  at  the  bottom  of  the 
vessel,  the  water  not  containing  a  particle  of  it. 
A  thorough  scrubbing  of  the  field  of  operation  is 
deemed  absurd,  inasmuch  as  after  the  incision  Is 


286  SURGICAL   ASEPSIS. 

made  irrio^ation  with  a  strono;  bichloride  solution 
is  credited  with  the  power  of  washing  away  all 
the  sins  of  omission  or  of  any  imaginable  kind 
of  commission.  If,  notwithstandinor  these  alleged 
precautions,  it  so  happens  that  one  or  more 
microbes  escape  being  killed,  then  the  dusting 
over  the  wound-surfaces  of  iodoform  powder  is 
expected  to  destroy  the  microbes   entirely. 

The  writer  has  heard  similar  ideas  expressed 
by  colleagues  who  enjoyed  the  full  confidence 
of  the  community.  If,  to  the  surprise  of  the 
"antiseptic"  colleague,  sepsis  sets  in,  he  emphat- 
ically asserts  that  the  strictest  antiseptic  precau- 
tions were  taken,  and  that  for  some  unfortunate 
reason  there  must  have  been  some  agent  in  the 
system  predisposing  the  patient  to  this  fatal 
course.  He  has  done  all  he  could.  He  has 
not  only  used  bichloride,  carbolic  acid,  and  iodo- 
form, but  he  has  also  looked  the  latest  medical 
essays  over  and  employed  the  most  recent  anti- 
septic preparations.  But,  alas !  this  particular 
case  was  "  beyond  the  reach  of  science." 

Had  such  a  colleague  but  inspected  his  finger- 
nails, which  perhaps  sheltered  millions  of  mi- 
crobes, representing  a  graveyard,  so  to  say,  his 
patient  might  have  been  "  within  the  reach  of 
science."  This  assertion  would  seem  to  place 
his  entire  knowledge  of  the  principles  of  wound- 
treatment  on  a  level  with  that  of  the  laity,  among 


ASEPSIS  IN  PRIVATE   PRACTICE.  287 

whom  it  is  known  that  iodoform,  bichloride,  and 
carbohc  acid  are  good  antiseptic  medicaments. 

Only  a  short  time  ago  the  writer  met  an  old 
practitioner  who  had  been  advised  to  administer 
intra-uterine  douches,  and  who  remarked  with 
great  dignity  that  he  was  always  prepared  for  in- 
tra-uterine cases  in  carrying  a  good-sized  metal 
catheter  with  him.  He  produced  a  discolored 
instrument  which  looked  as  if  it  miorht  have 
been  exhumed  at  Pompeii.  When  the  writer 
doubted  the  aseptic  condition  of  the  catheter 
this  learned  colleague  gave  a  look  of  unutterable 
contempt,  put  the  catheter  to  his  lips,  and  blew 
through  the  instrument  to  prove  that  it  was  still 
permeable.  Thoroughly  satisfied  with  this  pro- 
cedure, he  exclaimed,  "  What  objection  can  be 
found  to  this  catheter?  It  is  all  ri^ht.  It  con- 
tains  no  sanoruinolent  incrustations  Y' 

Allusion  to  this  instance  is  made  simply  to 
illustrate  the  deplorable  fact  that  there  are  some 
men  still  oblivious  of  the  advances  of  the  times. 

But  there  is  another,  happily  the  larger,  class 
of  colleagues  professionally  developed  to  a  much 
higher  degree,  who  are  always  in  the  vanguard 
when  anything  new  and  rational  appears.  They 
are  perfectly  modern.  A  fortnight  ago  they  fol- 
lowed antisepsis  ;  to-day  they  creditably  strive  for 
asepsis.  They  sterilize  their  dressing  material, 
they  boil  their  instruments,  they  possess  the  best 


2SS  SURGICAL  ASEPSIS. 

modern  aseptic  appliances,  and  they  evince  a 
disposition  to  attain  the  very  best  results ;  but, 
commendable  as  these  efforts  are,  they  do  not 
go  far  enough.  Many  of  them  place  properly- 
sterilized  dressing  materials  upon  an  unclean 
lounge  ;  they  rest  upon  soiled  bed-sheets  instru- 
ments which  had  been  sterilized  ;  their  disinfected 
hands,  after  having  been  brought  into  contact 
with  uncleansed  parts  of  the  body,  are  introduced 
into  the  wound ;  and  other  similar  infractions  are 
committed,  thus  violating  every  principle  upon 
which  asepsis  is  based. 

No  stone,  however,  should  be  cast  at  such 
men,  for  they  do  the  best  they  can.  In  shoi^t, 
non-compliance  with  aseptic  rides  is  si7nply  due 
to  ignorance  of  them.  The  whole  profession 
must  be  so  thoroughly  imbued  with  the  princi- 
ples and  so  permeated  with  the  practice  that  the 
exercise  of  aseptic  rules  becomes  a  mere  matter 
of  routine.  That  w^e  are  far  from  having  reached 
this  desirable  stage  was  never  more  evident  to 
the  writer  than  when,  only  recently,  he  saw  an 
eminent  surgeon  insert  his  hand,  ornamented 
with  several  rings,  into  a  human  abdomen.  If 
such  men  thus  err,  what  can  be  expected  of  the 
average  practitioner? 

When  antisepsis  was  first  broached  In  clinics  the 
country  physician  ridiculed  the  new  method.  The 
writer  remembers  hearing  an  old  German  '*  Medl- 


ASEPSIS  IN  PRIVATE   PRACTICE.  289 

clnal-Rath,"  sixteen  years  ago,  say  to  his  young 
assistant,  who  had  been  educated  at  Czerny's  cel- 
ebrated cHnic  at  Heidelberg,  when  offered  a  brush 
to  clean  his  fingers  :  "  A  brush  !  what  for  ?  All  this 
is  nothing  but  the  arrogance  of  young  medical 
men."  But  the  old  counsellor  eventually  grasped 
the  idea  that  he  could  not  very  well  disregard 
this  alleged  "arrogance,"  for  the  simple  reason 
that  the  public  began  to  know  something  of  the 
antiseptic  method.  The  present  transition  state 
is  somewhat  similar  to  the  period  of  early  Lis- 
terism,  and  it  is  clearly  incumbent  on  surgical 
specialists  to  impart  all  possible  instruction  on 
asepsis  to  general  practitioners.  Naturally,  it 
will  greatly  facilitate  the  introduction  of  asepsis 
if  its  methods  are  more  and  more  simplified.  But 
it  should  always  be  borne  in  mind  that  simplicity 
must  not  circumscribe  the  fundamental  princi- 
ples of  asepsis. 

The  manner  of  execution  of  aseptic  rules  is 
well  demonstrated  in  the  preparations  for  opera- 
tion in  a  private  dwelling.  Every  surgeon  must 
be  prepared  to  perform  operations  oittside  the 
hospital,  and,  if  necessary,  amid  the  poorest  sur- 
roundings. He  naturally  will  there  encounter  a 
great  many  more  difficulties  in  keeping  up  his 
asepsis  than  he  would  at  the  hospital.  But  all 
these  difficulties  will  be  overcome  by  one  accus- 
tomed  In  the  hospital   to  thorough  asepsis,  the 

19 


290  SURGICAL   ASEPSIS. 

principles  of  "which  he  will  be  able  to  carry  out 
amid  the  poorest  accommodations  of  the  back- 
woods. 

As  the  surgeon  must  always  be  prepared  for 
a  call,  he  should  therefore  have  a  set  of  asep- 
ticized surgical  appliances  ready  in  a  satchel  at 
his  ofhce.  The  writer  has  found  it  convenient 
to  preserve  the  instruments  generally  required 
in  linen  cases,  having  a  separate  case  for  abdom- 
inal sections,  one  for  operations  upon  the  bones, 
one  for  the  uropoietic  system,  one  for  trache- 
otomy, and  one  for  general  use  (Fig.  62).  These 
linen  cases  may  be  rolled  up  and  tied  in  the 
middle  with  a  cord  after  being  used.  The  case 
designated  by  the  writer  for  general  use  contains 
such  instruments  as  are  required  in  any  opera- 
tion— that  is,  scalpels,  scissors,  forceps,  retractors, 
spoons,  etc. — and  is  carried  along  with  the  one 
designated  for  a  special  operation.  For  instance, 
if  a  herniotomy  is  to  be  performed,  the  general 
set  is  accompanied  by  the  laparotomy  set.  By 
keeping  these  linen  cases  always  ready  we  may 
guard  against  the  necessity  of  sending  from  the 
patient's  house  for  a  forgotten  instrument. 

The  pocket  case  devised  by  the  writer  actually 
represents  the  linen  case  en  miiiiaiure.  With  a  few 
buttons  it  is  fastened  to  a  leather  case,  and  it  may 
be  carried  in  a  pocket  conveniendy.  By  boiling 
the  linen  sheet  it  can  easily  be  rendered  sterile. 


ASEPSIS  IN  PRIVATE   PRACTICE. 


291 


The  instrument-cases  can  be  carried  alone 
with  the  other  necessaries  In  a  satchel.  The 
writer  uses  a  satchel  of  rectangular  shape  forty 


Fig.  62. — Linen  instrument-case  (for  general  use). 

centimetres  long,  which  gives  ample  space  for  the 
instruments  required,  as  well  as  for  the  other  nec- 
essaries, consisting  of  a  folding  sterilizer  (Fig,  ^^l), 
trays  (Fig.  23)  fitting  one  into  another,  gauze  and 
cotton  as  dressing  and  sponging  ma- 
terial, moss,  bandages,  silk,  catgut, 
rubber  gloves,  green  soap,  brushes, 
soda,  bichloride  tablets,  ether,  chloro- 
form, morphine  tablets,  and  campho- 
rated oil.  It  will  sometimes  be  con- 
venient to  carry  the  surgeon's  coats, 
towels,  sheets,  etc.  to  the  house  also.  i\mong  the 
utensils  the  first  and  most  Important  is  the  boiler. 


Fig.   63. — Sim- 
ple boiling-pot. 


292 


SURGICAL   ASEPSIS. 


If  a  physician  cannot  afford  the  luxury  of  a  ster- 
ihzer,  he  may  order  several  enamelled  pots  (Fig. 
63)  to  take  its  place.  A  folding  stand  such  as  is 
described  on  page  1 10,  costing  fifty  cents,  may  be 
carried  in  a  satchel. 

Most  patients,  however,  would  not  object  to 
expending  seventy-five  cents  or  a  dollar  for  a 
"royal  baking-pan"  (Fig.  64),  which,  being  pro- 
vided with  a  small  stand,  is  sufficiently  spacious 

to  sterilize  both  the  in- 
struments and  the  mate- 
rials for  an  operation. 
The  brushes  for  scrub- 
bing the  skin-surfaces,  if 
sterilized,  can  be  carried 
in  aseptic  towels,  as  well 
as  the  gauze  and  other 
dressing  material.  The  ligatures  are  kept  best 
in  one  of  the  metal  boxes  described  on  pages 
135  and  136.  Iodoform  gauze  may  be  carried 
conveniently  in  a  receptacle  such  as  the  one  de- 
vised by  Duhrssen  (Fig.  65).  If  a  pot  should  not 
be  at  hand,  it  should  be  remembered  that  small 
instruments,  such  as  needles,  canulas,  bistouries, 
etc.,  may  be  sterilized  by  boiling  them  in  a  table- 
spoonful  of  water  held  above  a  candle. 

The  patient's  family  should  be  instructed  to 
keep  an  abundant  supply  of  boiling  water  ready 
in  large  vessels,  and  there  should  be  at  hand  a 


Fig.  64. — Baking-pan. 


ASEPSIS  IN  PRIVATE   PRACTICE. 


^93 


Fig.  65. — a,  Aseptic  re- 
ceptacle for  iodoform  gauze ; 
b,  the  case  (Diihrssen). 


sufficient  number  of  linen  bed-sheets  and  plenty 
of  towels.  If  the  tin  boilers  which  are  so  much 
en  vogue  are  used,  they  should  be  scrubbed  well 
with  sapolio  before  being 
used  for  surgical  purposes. 
Before  being  put  in  use  they 
should  be  covered  with  ster- 
ilized towels,  and  the  arrange- 
ments with  the  sterilized 
water  should  be  supervised 
by  an  assistant  or  nurse.  It 
is  well  to  have  ready  several 
china  pitchers  and  basins  pre- 
viously scrubbed  in  the  same 
manner  as  the  tin  boilers,  and  afterward  washed 
with  a  stronor  bichloride  solution.  If  basins  or 
bowls  cannot  be  procured  for  the  instruments, 
they  may  rest  upon  sterilized  towels. 

The  operati7ig-room  in  a  private  diuelling  (com- 
pare Section  VIII.)  should  be  well  lighted.  It  is 
wise  to  send  an  assistant  to  the  house  at  least 
one  day  before  the  operation,  to  see  that  the 
room  is  prepared  in  accordance  with  the  rules 
given  on  page  151.  A  strong  table  may  be 
selected  for  an  operating-table.  In  addition, 
there  should  be  provided  two  other  tables,  of 
nearly  equal  size,  upon  which  to  place  the  instru- 
ments, the  trays,  the  gauze  mops,  the  silk,  and 
other  materials.    If  the  extra  tables   cannot  be 


294  SURGICAL  ASEPSIS. 

obtained,  a    number  of   wooden    chairs  may  be 
substituted. 

Tables  and  chairs  should  be  scrubbed  with 
soap  and  boiling-  water,  and  with  bichloride  on 
the  day  before  the  operation.  It  is  also  advisable 
to  send  a  nurse  to  the  patient's  home  at  least 
twenty-four  hours  before  the  operation  is  to  take 
place,  to  make  the  necessary  arrangements  in  the 
operating-room,  and  to  see  that  the  patient  takes 
a  warm  bath  and  is  prepared  in  accordance  with 
the  directions  oriven  in  Section  IV.  It  is  a  ereat 
convenience  for  the  nurse  to  have  an  operation 
blank  such  as  that  prepared  by  Dr.  Keen  of 
Philadelphia.^  On  this  blank  all  the  necessary 
preliminary  arrangements  to  be  made  by  the 
nurse  are  clearly  defined. 

It  is  furthermore  necessary  to  send  another 
assistant  to  the  patient's  dwelling  at  least  two 
hours  before  the  time  set  for  the  operation. 
This  assistant  should  arrange  the  sterilizer  by 
putting  in  the  soda-solution,  lighting  the  lamp, 
and  depositing  the  instruments,  towels,  dressing 
materials,  ligatures,  etc.  He  then  renders  him- 
self aseptic  as  described  in  Section  V.  Having 
protected  his  hands  with  sterilized  gloves,  the 
assistant  places  in  the  lightest  part  of  the  room 
the  operating-table,  and  arranges  in  their  proper 
positions  the  tables  or  chairs  for  the  instruments. 

»  Published  by  VV.  B.  Saunders,  Philada. 


ASEPSIS  IN  PRIVATE   PRACTICE.  295 

The  instruments,  which  meanwhile  have  become 
sterile,  are  placed  on  the  tables  and  chairs,  which 
must  first  be  covered  with  sterilized  towels  or 
with  sheets,  these  tables  being  so  located  that 
the  instruments  are  within  easy  reach  of  the 
operating  surgeon. 

If  much  sterilized  water  is  required,  it  should 
be  brought  from  the  sterilizing  utensil  in  clean 
pitchers  the  handles  of  which  are  surrounded  by 
sterilized  gauze  or  towels.  Within  easy  reach  of 
the  operating  surgeon  should  also  stand  two 
basins,  one  of  which  should  contain  sterile  water, 
the  other  one  bichloride. 

Only  after  all  the  above  preparations  are 
finished  may  the  anaesthesia  begin.  It  is  prefer- 
able that  the  anaesthetic  be  admnnistered  in  an 
adjoining  room.  In  the  meanwhile  the  assistant 
should  remove  his  gloves  and  again  disinfect  his 
hands.  All  the  other  assistants  and  the  nurses, 
if  called  on  to  perform  any  non-aseptic  manip- 
ulations— as,  for  instance,  helping  to  carry  the 
patient  upon  the  operating-table — should,  if  pos- 
sible, wear  gloves  while  doing  so.  The  operating 
surgeon  should  also  be  present  at  the  patient's 
home  as  early  as  possible,  so  as  to  control  the 
preliminary  arrangements  and  to  give  ample 
time  for  rendering  himself  thoroughly  aseptic. 

When  only  an  ordinary  pot  can  be  obtained, 
the  towels,  etc.  must  be  boiled  in  the  water;  this, 


296  SURGICAL    ASEPSIS. 

however,  necessitates  using  the  materials  in  a 
moist  state. 

After  the  patient  is  laid  upon  a  fresh  linen 
bed-sheet,  preferably  a  sterilized  one,  the  field 
of  operation  must  be  scrubbed  thoroughly  with 
warm  water  and  soap  (compare  Section  IV.,  on 
Prophylactic  Disinfection).  The  area  is  then 
dried  with  towels  and  is  ao-ain  washed  with  alco- 

o 

hoi  and  bichloride.  Sterilized  towels  from  the 
sterilizer  are  now  taken  to  surround  the  field  of 
operation.  Before  any  object  is  removed  from 
the  sterilizer  the  surgeon  and  his  assistants,  and 
whoever  else  participates  in  any  part  of  the 
operation,  must,  of  course,  have  disinfected  their 
hands.  When  the  surgeon  and  his  assistants  are 
prevented  from  using  operating-suits,  the  latter 
must  be  substituted  by  sterilized  bed-sheets  or 
shirts,  or  at  least  by  one  or  two  sterilized  towels 
fastened  over  the  chest  and  abdomen  by  safety- 
pins.  During  the  entire  operation  no  antiseptic 
fluid  is  required.  Gauze  mops  cut  into  short 
pieces  before  sterilization  answer  every  purpose 
of  cleanliness.  They  may  be  wrapped  in  a  towel 
the  ends  of  which  are  pinned  together  to  protect 
the  mops. 

These  procedures  will  doubtless  appear  strange 
when  first  employed  by  one  unaccustomed  to 
asepsis.  The  feature  most  likely  to  disconcert 
the  inexperienced  surgeon   is   the  exclusion  of 


ASEPSIS  IN  PRIVATE   PRACTICE.  297 

all  chemicals  during  operation.  But  this  initial 
stage  of  novelty  soon  passes  off,  and  every  step 
and  detail  quickly  becomes  a  matter  of  salutary 
habit. 

The  surgeon  should  closely  scrutinize  his 
every  act,  and  should  always  bear  in  mind  that 
no  wound,  whether  clean  or  otherwise,  should 
ever  be  treated  with  a  non-disinfected  hand. 
Furthermore,  he  should  not  bring  into  contact 
with  the  wound  any  article  or  instrument  unless 
it  has  been  sterilized  thoroughly.  The  surgeon 
should  be  equally  scrupulous  in  his  private  office. 
He  should  imatate  the  conditions  of  the  aseptic 
operating-room  (see  Section  VIII.)  as  much  as 
possible,  and  should  always  have  boiling  water 
at  hand.  If  he  seriously  desires  to  be  aseptic,  a 
few  days'  practice  will  thoroughly  accustom  him 
to  the  new  manipulations.  This  remark  refers 
especially  to  repeated  prophylactic  disinfection 
of  his  hands  and  of  all  the  objects  that  may 
come  into  contact  with  a  wound.  This  training 
wall  teach  the  avoidance  of  manipulations  w^hich 
may  appear  innocent  on  superficial  examination, 
and  yet  may  cost  a  human  life. 

There  is  no  excuse  for  a  surgeon  to  claim 
that  *'  the  poor  circumstances  of  the  patient's 
surroundings  did  not  permit  aseptic  precautions." 
Water,  fire,  and  boiling-pots  can  everywhere  be 
obtained,  so  that   instruments,  silk  or   common 


298  SURGICAL   ASEPSIS. 

thread,  and  dressings  can  be  sterilized.  If  no 
dressing  material  be  at  hand,  old  linen  may  be 
boiled  and  substituted.  It  is  true  that  the  dress- 
ings are  then  moist,  but  nevertheless  they  are 
sterile.  Freshly-washed  and  ironed  linen,  how- 
ever, is  generally  sterile,  and  may  be  substituted 
for  the  oauze. 

Public  attention  should  be  called  to  the  great 
importance  of  the  above  points,  so  as  to  render 
the  aseptic  surgeon  valuable  support.  Many 
persons  die  from  the  consequences  of  having  cut 
their  corns  with  an  unclean  razor  or  from  having 
opened  a  small  abscess  with  a  dirty  pin.  Had 
they  been  told  that  the  parts  should  have  been 
washed  carefully  and  that  the  razor  should  have 
been  boiled  for  a  few  seconds,  they  would  not 
have  succumbed  to  the  most  fell  of  all  destroy- 
ers— ignorance.  It  is  a  widespread  custom  to 
wash  wounds  with  water  without  being  scrupu- 
lous as  to  its  source.  It  may  be  from  a  muddy 
pool  or  from  a  dirty  vessel,  and  be  spread  over 
the  wound  to  "render  it  clean."  The  public 
should  also  be  instructed  that  wounds  must  be 
disturbed  as  litde  as  possible,  and  that  only  when 
there  is  considerable  hemorrhage  should  the 
bleeding  region  be  pressed  for  five  minutes  (or 
until  the  arrival  of  the  surgeon)  with  a  towel  or 
a  linen  compress  previously  immersed  in  boiling 
water. 


ASEPSIS  IN  PRIVATE   PRACTICE.  2gg 

A  most  interesting  paper,  read  before  the 
New  York  Academy  of  Medicine  (May  i8,  1894) 
and  published  in  the  American  Medico-Surgical 
Bulletin  for  June  15,  1894,  by  Surgeon-General 
Joseph  D.  Bryant,  on  "The  Fallibility  of  Human 
Effort  in  Aseptic  Surgery,"  illustrates  what  the 
writer  has  before  emphasized^namely,  that  if 
ninety-nine  points  of  precaution  are  originally 
observed,  while  the  hundredth  is  omitted,  the 
result  may  be  the  same  as  if  no  precautions 
whatever  had  been  taken. 

Bryant  wired  a  comminuted  fracture  of  the 
patella  uncomplicated  by  external  opening.  Al- 
though strict  aseptic  precautions  were  taken,  the 
joint  suppurated  and  the  patient  died.  The  sup- 
puration began  superficially  in  the  line  of  several 
strands  of  catgut  placed  to  facilitate  drainage. 
The  question  then  arose  as  to  the  cause  of 
the  infection.  Samples  of  each  of  the  agents 
employed  in  dressing  the  wound  were  submitted 
to  the  biological  scrutiny  of  Professor  Dunham 
of  New  York,  wn'th  negative  results  in  every 
instance.  As  the  necessary  precautions  in  other 
respects  were  believed  to  have  been  taken, 
Bryant  was  puzzled  as  to  the  cause  oi  infection. 
Finally,  before  attributing  the  infection  to  "un- 
known influences,"  he  decided  to  take  the  class 
into  his  confidence.  He  stated  to  the  student 
members   the    sequel   to  the    operation  and  the 


30O  SURGICAL  ASEPSIS. 

apparent  mystery  surrounding  the  wound-infec- 
tion, at  the  same  time  inviting  their  closest 
scrutiny  and  the  frank  expression  of  any  defect 
in  technique  that  might  be  observed  in  any 
subsequent  operations.  This  proposition  bore 
immediate  fruit  in  the  form  of  a  written  commu- 
nication from  a  student  who  modestly  suggested 
that  the  infection  mio^ht  be  due  to  the  fact  that 
the  assistant  who  had  plaited  the  catgut  had 
placed  on  the  table  with  the  other  instruments, 
without  first  cleansing  it,  a  probe  which  had  been 
used  just  before  to  explore  an  intestinal  sinus. 

Bryant  correctly  says  that  we  should  not  un- 
duly criticise  the  momentary  forgetfulness  of  the 
assistant  who  thus  unconsciously  violated  an 
aseptic  law,  but  that  we  should  recall  the  biblical 
phrase  regarding  "  motes  and  beams,"  and  make 
a  retrospective  examination  of  the  effects  of  our 
own  foro^etful  moments. 

All  honor  to  men  who  do  not  refrain  from  crit- 
icisine  their   own   unfortunate   cases.     Thus  we 

o 

profit,  and  in  asepsis  more  than  in  aught  else 
should  be  remembered  the  old  sentence  in  the 
temple  at  Delphi:   ''Tvddi  deavrov^ 


INDEX. 


Abbe's  illumination,  30 
Abdomen,  sterilization  of,  96 
Abdominal  cavity,  antiseptic  solution 
in  the,  57 

drainage,  209 
Absorbent  gauze,  121 

power  of  dressings,  121 
Accidents  from  carbolic  acid,  77 
Acquired  immunity,  70 
Actinomyces,  46 
Aerobic  microbes,  27,  176 
Alcohol  in  skin-disinfection,  93 
Alummum  aceticum,  81 
Anaesthesia,    abstinence    from    food 
before,  271 

cause  of  death  in,  276 

dangers  of,  243,  269 

general  rules  to  be  observed  in,  272 

its  importance  for  asepsis,  270 

limited,  277 

starting  of,  246 
An£esthetizing-room,  246 
Antagonistic  microbes,  JT, 
Antisepsis,  53 
Antiseptics,  55 
Antitoxic  substances,  60 
Apparatus,    Braatz's,   for    sterilizing 

catgut,  127 
Aristol,  88 
Artificial  immunity,  70 

respiration,  technique  of,  279 
Ascococcus.     See  Staphvlococciis. 
Asepsis,  fallibility  of    human    efforts 

in,  299 
Aseptic  fever,  170 

injection,  253 

preparations  before,  253 

operation,  technique  of,  in  a  hos- 
pital, 239 


Aseptic   operation,  technique   of,  in 
private  practice,  284 
wounds,  159 

Assignments  of  duties  to  assistants, 
244 

Assistance,  non-aseptic,  245 

Assistants,  240,  294 

Atmosphere    as  a   carrier  of   micro- 
organisms, 19 

Atmospheric  infection,  47 

Bacilli  in  general,  22 
Bacillus  anthracis,  44 

coli  communis,  41 

diphtheriae,  45,  68 

fluorescens  putidus,  74 

prodigiosus,  46 

tetani,  43 

tuberculosis,  42 
Bacteria  in  general,  22 
Bacteriological  examination,  methods 
of  making,  29 

examinations     before     operations, 
88 
Bacterio-proteine,  50 
Bacterium     coli      commune.         See 

Bacillus  coli  communis. 
Baking-pan  as  a  sterilizer,  292 
Bandages,  124 
Bathing    of    the    patient,    95,    158, 

239 
Beards  as  an  aseptic  obstacle,  242 

Bichloride  of  mercur\',  78 
Bladder,  disinfection  of,  99 

treatment  after  operation  upon  the, 
214 
Bladder-pistol,  Beck's,  87 
Blisters  in  infected  wounds,  182 
Boiling  water  as  a  disinfectant,  65 

301 


302 


INDEX. 


Boric  acid,  8 1 

Box,   metal,    Beck's,   for    sterilizing 
and  preserving  catgut  or  silk, 
136 
Braatz's,    for   sterilizing    catgut, 

126 
Schimmelbusch's,  for  sterilizing 
silk,  135 
Braatz's  nail-cleaner,  92 
pedal,  95 

sterilizing  apparatus,  127 
Brush,  importance  of,  102 
Brush-box,  102 
Buried  sutures,  160,  169,  182 

Cadaver-alkaloids,  26 

Caps,  linen,  for  surgeons  and  nurses, 

241 
Carbolic  acid,  76 

Catgut,  boxes    for   preservation   of, 
126,  136 

jars  for  preservation  of,  128" 

sterilization  of,  125 

unreliability  of,  128 
Catheters,  disinfection  of,  99 
Cavities,  disinfection  of,  190 

renewal  of  dressing  in,  221 
Cells  of  microbes,  23 
Cellulitis,  173 
Chemotaxis,  35 
Chloride  of  zinc,  80 
Chloroform,     administration    of,     by 
dropping,  274 

danger  of,  280 

discovery  of,  268 

indications    and    contraindications 
for  administration  of,  270 

mask.     See  InJialer. 
Clover  inhaler,  272 
Coats,   surgeons'    and    nurses'.    See 

Suits. 
Cocaine  anaesthesia,  283 
Coccoglia,  24 
Coccus.     See  Micrococcus. 
Compound     fractures,    renewal    of 

dressings  in,  235 
Cones  for  anaesthesia,  272 
Contact-infection,  48,   146,  148,  150 
Continued  suture,  163,  216 
Corrosive  sublimate.   See  Bichloride 
of  mercury. 


Cultivating  microbes,  29,  33 
Cystitis,  microbes  concerned  in,  99 

Dermatol,  88 

gauze,  124 
Dermatoses,  226 

Diphtheria,  treatment   of,  by   injec- 
tion of  serum,  73 
by  removal  of  membranes,  68 
by    sub-membranous    injection, 
69 
Diplococcus  pneumonia,  40 
Disinfectants,  influence  of,  on  diph- 
theria, 68 
on  infected  wounds,  172,  184 
Disinfection,    determination    of    the 
kind  of,  88 
general,  by  inoculation,  75 
in  a  hospital,  158 
of  catgut,  125 
of  drainage-tubes,  139 
of  dressings,  no 
of  instruments,  104 
of  silk,  133 
of  sponges,  157 
of  the  bladder,  99 
of  the  feet,  95 
of  the  finger-nails,  92 
of  the  hands  of  the  surgeon,  92, 

93 
of  the  mouth,  loi 

of  the  mucous  membranes,  97 

of  the  nose,  loi 

of  the  operating-room,  144 

of  the  rectum,  98 

of  the  skin  of  the  patient,  95 

of  the  surgeon,  103 

of  the  vagina,  97 

selection  of  the  kind  of,  188 

technique  of,  shortly  before  opera- 
tion, 247 
Drainage  by  gauze,  184,  208 
Drainage-tubes,  disadvantages  of,  191 

indications  for,  212,  219 
Draining  in  intestinal  operations,  207 

in  operations  upon  the    gall-jjlad- 
der,  208 

in  operations  upon  the  liver,  205 

in  tuberculosis,  206 

metlKKJical,    by    iodoform    gauze, 
190,  198 


INDEX. 


303 


Dressing    material,   sterilization   of, 
no 

renewal  of,  214,  225 

secondary,  218 
Dryness,  antiseptic  influence  of,  66 
Dust  in  operating-room,  152 

Eczema,  symptoms  of,  227 
Electric  lamps,  sterilization  of,  109 
Electricity  as  a  disinfectant,  61 
Erysipelas,  173,  230 
Eiythema,  septic,  230 
Esmarch's  constriction,  194,  222 
Ether,  dangers  of,  280 

discovery  of,  268 

indications    and    contraindications 
for  administration  of,  270 
Etherization,  albumen  in  urine  after, 
269 

Finger-nails,  care  of,  92 
Folding  stand.  Beck's,  no 
Fractures,   compound,    dressings   in, 

235 
treatment  of,  187 

Gall-bladder,  open  treatment  after 

operation  on  the,  208 
Gangrene  of  the  lips  of  a  wound,  183 
Gauze  bag,  Mikulicz's,  209 

disinfection  of,  67 

shortly  before  operation,  248 

drain,  218. 

iodoformized.  See  Iodoform  gauze. 

packing,  198 
temporary,  211 

preservation  of  sterilized,  114 
Glass  drainage-tubes,  141 

jars  for  preserving  catgut,  128 

shelves  in  operating-room,  145 
Gloves  of  linen  or  of  rubber  dam,  94 
Glycerin  as  a  constituent  of  iodoform, 

263 
Gonococcus,  39 

Granulations  of  wound-surfaces,  197 
Green  soap,  92,  96,  loi 
Gunshot  wounds,  187 

Hairs,  shaving  of,  97 

Hanging  drop,  examination  of,  32 

Hard-rubber  tubes,  141 


Heat  as  a  disinfectant,  63 

Hemorrhage  after  laparotomy,  223 
from    brain-sinuses,  treatment    of, 

210 
secondar)',  220 

Hippocratic  area,  asepsis  in  the,  58 

Hotzen's  syringe,  267 

Hyperasmia,  antitubercular  influence 
of  artificial,  258 

Hypodermatic  injections.    See  Injec- 
tions. 

Hypodermic  syringes.   See  Syringes. 

Immobilization    in    wound    treat- 
ment, 122,  168,  195,  200,  252, 
261 
Immunity,  70 
Importance  of  asepsis,  53 
Incubator,  31 
Infected  wounds,  171 
Infection  following  injection,  253 

symptoms  of,  178 
Inflammation  of  wound-edges,   180, 

232 
Inhaler,  Braatz's,  274 

choice  of,  271 
Injection  dosage  of  iodoform,  261 

fluid,  sterility  of,  255 
Inoculating  animals,  -^t^ 
Inoculation  by  scratching,  49,  70 

for  curing  malignant  diseases,  74 

of  the  tubercular  bacillus,  258 

with  putrid  fluids,  174 
Intestines,  iodoform  gauze  in  opera- 
tions on,  207 
Iodoform  as  a  drug,  Zt^ 

as  an  ethereal  solution,  85,  97,  256, 
262,  264 

collodion,  87,  97 

eczema,  226 

symptoms  of,  227 

emulsion,  sterilization  of,  256 

gauze,  preparation  of,  123 

glycerin,  85,  262 

idiosyncrasy,  86,  229 

oil,  258,  262 

suppositories,  87 

tul)erculocidal  influence  of,  257 

value  of,  as  an  injection,  S3,  255 
Irrigation  fluid,  142 

trocar.  Beck's,  259 


304 


INDEX. 


Irrigator,  136 
Isolating  microbes,  29 

Kelly's  (Howard)  method  of  dis- 
infection, 93 

Kidneys,  open  treatment  after  opera- 
tions on,  211 
preparations  before  operations  on, 
100 

Knives,  disinfection  of,  106 

Koch's  syiinge,  266 

Kiimmel's  method  of  disinfection, 
92 

Laity,  instruction  of,  in  the  treat- 
ment of  wounds,  297 

Laparotomy,  preparation  for,  96 

Leucocytes,  50 

Leucomaines,  26 

Ligature-bottle,  133 

Linear  cultures,  33 

Liver,  open  treatment  in  operations 
on,  208 

Local  anaesthesia,  282 

Maxilla-separator,  Beck's,  275, 

279.  . 
Means  of  disinfection,  60 
Mechanical  disinfection,  61,  104 
Microbes,  cultivation  of,  20 

influence  of,  17 

multiplication  of,  19 
Micrococcus,  22 
Micro-organisms  in  general,  17 
Microscopical    examinations    during 

operation,  89 
Mirrors,  sterilization  of,  109 
Mitigated  cultures,  71,  72 
Moist     blood -clot,    Schede's,     142, 

159 
Moisture  in  putrid  wounds,  198 
Morphine  injections,  253 
Moss  board,  122,  195,  252 
Moulds.    See  Fungi. 
Mouth,  disinfection  of,  loi 
Mucous  membranes,  disinfection  of, 

97 
Mycotozoa  (protozoa),  17 

Necrosis  of  wound-margins,  230 
Needle-point  cultures,  2>Z 


Nose,  disinfection  of,  loi 
Nurses,  240,  245,  294 

Obligate  microbes,  31 
Occluded  wounds,  161 
Office,    arrangement    of    surgeon's, 

297 
Olive  oil  as  a  constituent  of  iodo- 
form emulsion,  263 
Open-wound  treatment,  1 86 
Operating-room,  143 

determining  the  presence  of  mi- 
crobes in,  147 
dissemination  of  microbes  in,  146 
private,  arrangement  of,  1 5 1 
Operating-suits,  241,  247 
Operating-table,  152 
Operation,  aseptic,  technique  of,  in 
a  hospital,  239,  243 
in  private  practice,  284 
Operation-blank,  Keen's,  294 

Pails,  158 

Pain  in  wounds,  236 

Pathogenic  microbes,  21,  28 

Patient's  family,  instructions  to,  be- 
fore operation,  292 

Pelvic  organs,  treatment  after  opera- 
tion on  the,  210 

Perineal  section,  treatment  after,  214 

Peritoneum.    See  Abdominal  cavity. 

Peroxide  of  hydrogen,  82 

Petri's  plates,  33 

Phagocytes,  71 

Phenol,  76 

Phlegmon,  173,  183 

Phlogosin,  35,  50 

Plastic  operations,  removal  of  sutures 
after,  215 

Pneumococcus,  Friedlander's,  41 

Pocket  case  for  instruments,  290 

Pot  as  a  sterilizer,  105,  291 

Preparations   before   operation,  239, 
243,  246 
in  emergencies,  240 
for  a  special  operation,  249 

Pressure  in  the  treatment  of  wounds, 

233 
Primary  union,  159, 

partial,  223 
Private  rooms,  158 


INDEX. 


305 


Procedures  before  and  during  opera- 
tions, 249 
Prophylactic  suture,  166 
Ptomaines,  26 

Pus-retention  after  suturing,  182,  224 
Putrefaction.   See  Sepsis. 
Pyeemia,  173 
Pyogenic  cocci,  36 
Pyothorax,  bacteriological  examina- 
tion of  pus  in,  90 

Diplococcus  pneumonias  in,  40 

drainage  in,  234 

Staphylococcus  aureus  in,  37 

treatment  in,  212 
Pyrozone,  82 

Rectum,  disinfection  of,  98 
Reels  for  silk  sutures,  134 
Relaxation-sutures,  164 
Rubber     catheters,    sterilization    of, 
109 

drainage-tubes.    See  Drainage. 

gloves,  94 

Salicylated  gauze,  1 24 
Salicylic  acid,  81 
Salol,  100 
Saprophytes,  20,  22 
Schizomycetes,  17,  18 
Schmidt's  aseptic  syringe,  267 
Sepsis,  173 

definition  of,  17 
Septic  fever,  170,  179 
Septogenic   microbes,    differentiation 
of,  176 

organisms,  28 
Sharp  spoon,  205 
Silkworm  gut,  136 
Silver  wire,  136 
Silver- wire  suture,  166 
Situation-sutures,  166 
Skin,  disinfection  of,  92,  95 
Soap,  loi 

Soda,  chemical  composition  of,  106 
Soda-solution,  efficiency  of,  105 
Sounds,  disinfection  of,  99 
Specific  contagious  diseases,  52 

ulcers,  234 
Spectators  in  operating-room,  145 
Spirillum,  22 
Spirochaete.     See  Spirillum. 

20 


Splint,  Beck's  extractable,  for  non- 
united  fractures,  236 
Sponges,  137 
Spores,  62 

Staining  microbes,  30 
Staphylococcus,  24 

pyogenes  aureus,  35 
citreus,  38 
Steam  as  a  disinfectant,  63 
Sterilization,  definition  of,  107 

of  catgut,  125 

of  drainage-tubes,  139 

of  silk,  133 

of  sponges,  137 

uncertainty  of,  128 
Sterilizer,  Beck's,  119 

Bra'atz's,  1 17 

Koch's,  1 1 1 

Korte's,  118 

Lautenschlager's,  112 

Mally's,  117 

Schimmelbusch's,  115 
Stitches,  removal  of,  215 
Stomach,   preparation   before   opera- 
tion on,  loi 
Streptobacterium .     See  Streptococcus 

pyogenes. 
Streptococcus  pyogenes,  24,  38 
Subcutaneous   sutures.     See  Buried 

sutures. 
Suits,  Beck's  sterilized,  for  patients, 
246 

sterilized,  for  surgeons  and  nurses, 
241,  247 
Sunlight  as  a  disinfectant,  61 
Suppuration,  35 

in  buried  sutures,  182 

of  stitch-canals,  181,  183 
Suprapubic  section,   treatment   after, 

214 
Suture-cases,  133 
Sutures,  extraction  of,  224,  231 
Suturing,  technique  of,  163 
Syringes,  hypodeniiic,  sterilization  of, 
265' 

Tabi-ES  for  basins,  145 

for  dressings  and  instruments,  154 
for  Trendelenburg's  position,  153 

Tartaric   acid  as  an  addition  to  bi- 
chloride, 80 


3o6 


INDEX. 


Technique  of  sponging,  250 
of  suturing,  163 

of  uniting  wounds,  after    Neuber, 
162 
Temperature  as  a  guide  in  treatment, 

236 
Tin  box,  Schimmelbusch's,  114 
Tongue-forceps,  Beck's,  275 
Torula.     See  Streptococcus. 
Towels,  disinfection  of,  248 

sterilized,  in  operation,  250 
Toxalbumins,  26 
Toxines,  26,  35 

Tuberculosis  peritonei,  treatment  of, 
261,  265 
surgical  treatment  of,  206 
Tuberculous  ulcers,  234 

Umbilicus,  disinfection  of,  97 


Urethra,  disinfection  of,  100 
Urine,  examination  of,  before  opera- 
tion, 239 
microbes  in,  99 

Vagina,  disinfection  of,  97 

Varicose  ulcers,  232 

Vibrio.     See  Spirillum. 

Von  Farkas'  steam-atomizer,  98,  108 

Wards  of  a  hospital,  158 
Water  for  sterilization,  142 
Water-supply  in  operating-room,  144 
Wire  splint,  Beck's  modification,  200 
Kramer's,  200 

Yeast  fungi,  17 

ZOOGLCEA,  25 


opkl 


PUBLISHED    BY 


W.  B.  SAUNDERS,  925  Walnut  Street,  Philadelphia,  Pa. 


PAGE 

♦American  Text-Book  of  Applied  Thera- 
peutics   3 

♦American  Text-Book  of  Diseases  of  Chil- 
dren     3 

♦American  Text-Book  of  Gynecology  .  .  4 
♦American  Text-Book  of  Nursing  ....  8 
♦American  Text-Book  of  Obstetrics  ...  8 
♦American  Text-Book  of  Physiology  ...  8 
♦American  Text-Book  of  Practice  ....  2 
♦American  Text-Book  of  Surgery     .    .    .    .     i 

Ashton's  Obstetrics 23 

Ball's  Bacteriology 27 

Bastin's  Laboratory  Exercises  in  Botany  .  18 

Beck's  Surgical  Asepsis 14 

Brockway's  Physics 27 

Burr's  Nervous  Diseases      12 

Cerna's  Notes  on  the  Newer  Remedies  .  .18 
Chapman's    Medical    Jurisprudence     and 

Toxicology 14 

Cohen  and  Eshner's  Diagnosis 26 

Cragin's  Gynaecology 24 

DaCosta's  Manual  of  Surgery 13 

♦De  Schweinitz's  Diseases  of  the  Eye    .    .    5 

Dorland's  Obstetrics      13 

Frothingham's     Guide    to    Bacteriological 

Laboratory      14 

Garrigues'  Diseases  of  Women 10 

Gleason's  Diseases  of  the  Ear 28 

Griffin's  Materia  Medica  and  Therapeutics  12 

♦Gross's  Autobiography 7 

Hare's  Physiology 22 

Hampton's    Nursing :    its    Principles   and 

Practice 15 

Hyde's  Syphilis  and  Venereal  Diseases  .  .  12 
Jackson  and  Gleason's  Diseases  of  the  Eye, 

Nose,  and  Throat      25 

Jewett's  Outlines  of  Obstetrics 18 

♦Keating's     Pronouncing     Dictionary    of 

Medicine      7 

Keating's   How  to   Examine  for  Life  In- 
surance      20 


PAGE 

Keen's  Operation  Blanks 16 

Kyle's  Diseases  of  Nose  and  Throat  ...  12 

Laine's  Temperature  Charts 9 

Lockwood's  Practice  of  Medicine    ....  12 

Long's  Syllabus  of  Gynecology 9 

Martin's  Surgery 22 

Martin's  Minor  Surgery,  Bandaging,  and 

Venereal  Diseases 25 

Morris'  Materia  Medica  and  Therapeutics  23 

Morris'  Practice  of  Medicine 24 

Morton's  Nurses'   Dictionary 9 

Nancrede's  Anatomy  and  Manual  of  Dis- 
section   16 

Nancrede's  Anatomy 22 

Norris'  Syllabus  of  Obstetrical  Lectures    .  17 

Powell's  Diseases  of  Children 26 

Raymond's  Physiology 13 

Saunders'  Pocket  Medical  Formulary  .  .  19 
Saunders'  Pocket  Medical  Lexicon  ....  19 
Saunders'  New  Aid  Series  of  Manuals  .  11,  12 
Saunders'  Series  of  Question  Compends   .  21 

Sayre's  Practice  of  Pharmacy 26 

Semple's  Pathology  and  ^lorbid  Anatomy  23 
Semple's  Legal  Medicine,  Toxicology,  and 

Hygiene 25 

Senn's  Syllabus  of  Lectures  on  Surgery  .    .  17 
Shaw's  Nervous  Diseases  and  Insanity  .    .  27 
Stelwagon's  Diseases  of  the  Skin    ....  24 
Stevens'   Materia  Medica  and  Therapeu- 
tics      20 

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sis   6 

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Wolff's  Examination  of  Urine 26 


Mr.  Satjnders,  in  presenting  to  the  profession  the  following  list  of  his  publications,  begs 
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THE  CARE  OF  THE  BABY.  By  J.  P.  Crozer  Griffith,  M.  D., 
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The  want  of  a  text-book  which  could  be  used  by  the  practitioner  and  at  the 
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ican Surgery,  yet  America  has  contributed  very  largely  to  the  progress  of  modern 
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and  science  will  be  found  the  authors  of  the  present  volume.  All  of  them  are 
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art  of  engraving  have  enabled  the  publisher  to  produce  illustrations  which  it  is 
believed  are  superior  to  those  in  any  similar  work. 

CONTRIBFTORS : 


Dr.  Charles  H.  Burnett,  Philadelphia. 
Phineas  S.  Conner,  Cincinnati. 
Frederic  S.  Dennis,  New  York. 
William  W.  Keen,  Philadelphia. 


Dr.  Nicholas  Senn,  ('hicago. 

Francis  J.  Shepherd.  Montreal,  Canada. 
Lewis  A.  Stimson,  New  York. 
William  Thom.^on,  Philadelphia. 


Charles  B.  Nancrede,  Ann  Arbor,  Mich.  |  J.  Collins  Warren,  Boston. 

Roswell  Park,  Buffalo,  N.  Y.  J.  William  White,  Philadelphia. 

Lewis  S.  Pilcher,  New  York.  I 

"  If  this  text-book  is  a  fair  refle.v  of  the  present  position  of  American  surgery,  we  must 
admit  it  is  of  a  very  high  order  of  merit,  and  that  English  surgeons  will  have  to  look  very 
carefully  to  their  laurels  if  they  are  to  preserve  a  position  in  the  van  of  surgical  practice." — 
London  Lancet. 

"  The  soundness  of  the  teachings  contained  in  this  work  needs  no  stronger  guarantee  than 
is  afforded  by  the  names  of  its  authors." — Medical  News,  Philadelphia. 


IV.   B.    SAUNDERS' 


For  Sale  by  Subscription. 


AN  AMERICAN  TEXT-BOOK  ON  THE  THEORY  AND 
PRACTICE  OF  MEDICINE.  By  American  Teachers.  Edited 
by  William  Pepper,  M.  D.,  LL.D.,  Provost  and  Professor  of  the  Theory 
and  Practice  of  Medicine  and  of  Clinical  Medicine  in  the  University  of 
Pennsylvania.  Complete  in  two  handsome  royal- octavo  volumes  of  about 
looo  pages  each,  with  illustrations  to  elucidate  the  text  wherever  necessary. 
Price  per  Volume  :  Cloth,  ^5.00  net;  Sheep,  ^6.00  net;  Half  Russia,  ^S^y.oo 
net. 

TOI.UME  I.  COXTAIXS: 


Hj'giene. — Fevers  (Ephemeral,  Simple  Con- 
tinued, Typhus,  Typhoid,  Epidemic  Cerebro- 
spinal Meningitis,  and  Relapsing). — Scarla- 
tina, Measles,  Rotheln,  Variola,  Varioloid, 
Vaccinia, Varicella,  Mumps, Whooping-cough, 
Anthrax,  Hydrophobia,  Trichinosis,  Actino- 


mycosis, Glanders,  and  Tetanus. — Tubercu- 
losis, Scrofula,  Syphilis,  Diphtheria,  Erysipe- 
las, Malaria,  Cholera,  and  Yellow  Fever. — 
Nervous,  Muscular,  and  Mental  Diseases  etc. 


VOIiUME   II.  CONTAINS: 

Urine  (Chemistry  and  Microscopy). — Kid-     — Peritoneum,  Liver, and  Pancreas. — Diathet- 


ney  and  Lungs. — Air-passages  (Larynx  and 
Bronchi)  and  Pleura. — Pharynx,  OEsophagus, 
Stomach  and  Intestines  (including  Intestinal 
Parasites),  Heart,  Aorta,  Arteries  and  Veins. 


ic  Diseases  (Rheumatism,  Rheumatoid  Ar- 
thritis, Gout,  Lithsemia,  and  Diabetes.) — 
Blood  and  Spleen. —Inflammation,  Embolism, 
Thrombosis,  Fever,  and  Bacteriology. 


The  articles  are  not  written  as  though  addressed  to  students  in  lectures,  but 
are  exhaustive  descriptions  of  diseases,  with  the  newest  facts  as  regards  Causa- 
tion, Symptomatology,  Diagnosis,  Prognosis,  and  Treatment,  including  a  large 
number  of  approved  formulae.  The  recent  advances  made  in  the  study 
of  the  bacterial  origin  of  various  diseases  are  fully  described,  as  well  as  the 
bearing  of  the  knowledge  so  gained  upon  prevention  and  cure.  The  subjects 
of  Bacteriology  as  a  whole  and  of  Immunity  are  fully  considered  in  a  separate 
section. 

Methods  of  diagnosis  are  given  the  most  minute  and  careful  attention,  thus 
enabling  the  reader  to  learn  the  very  latest  methods  of  investigation  without 
consulting  works  specially  devoted  to  the  subject. 


CONTRIBUTORS : 


Dr.  J.  S.  Billings,  Philadelphia. 
Francis  Delafield,  New  York. 
Reginald  11.  Fitz,  Boston. 
James  W.  Holland,  Philadelphia. 
Henry  M.  Lyman,  Chicago. 
William  Osier,  Baltimore. 


Dr.  William  Pepper,  Philadelphia. 
W.  Gilman  Thompson,  New  York. 
W.  H.  Welch,  Baltimore. 
James  T.  Whittaker,  Cincinnati. 
James  C.  Wilson,  Philadelphia. 
Horatio  C.  Wood,  Philadelphia. 


"  We  reviewed  the  first  volume  of  this  work,  and  said :  '  It  is  undoubtedly  one  of  the  best 
text-books  on  the  practice  of  medicine  which  we  possess.'  A  consideration  of  the  second 
and  last  volume  leads  us  to  modify  that  verdict  and  to  say  that  the  completed  work  is,  in  our 
opinion,  the  best  of  its  kind  it  has  ever  been  our  fortime  to  see.  It  is  complete,  thorough, 
accurate,  and  clear.  It  is  well  written,  well  arranged,  well  printed,  well  illustrated,  and  well 
bound.    It  is  a  model  of  what  the  modern  text-book  should  be." — New  York  J\7edical  yournal. 

"A  library  upon  modern  medical  art.  The  work  must  promote  the  wider  diffusion  of 
sound  knowledge." — American  Lancet. 

"A  trusty  counsellor  for  the  practitioner  or  senior  student,  on  which  he  may  implicitly 
rely." — Edinburgh  Medical  yournal. 


CATALOGUE   OF  MEDICAL    WORKS. 


For  Sale  by  Subscription. 


AN  AMERICAN  TEXT-BOOK  OF  THE  DISEASES  OF  CHIL- 
DREN. By  American  Teachers.  Edited  by  Louis  Starr,  M.  D., 
assisted  by  ThOxMPSON  S.  Westcott,  M.  D.  In  one  handsome  royal-8vo 
volume  of  1 190  pages,  profusely  illustrated  with  wood-cuts,  half-tone  and 
colored  plates.    Net  Prices  :  Cloth,  ^7.00 ;  Sheep,  ;^8.oo ;  Half  Russia,  ;^9.oo. 

The  plan  of  this  work  embraces  a  series  of  original  articles  written  by  some 
sixty  well-known  paediatrists,  representing  collectively  the  teachings  of  the  most 
prominent  medical  schools  and  colleges  of  America.  The  work  is  intended  to 
be  a  PRACTICAL  book,  suitable  for  constant  and  handy  reference  by  the  practi- 
tioner and  the  advanced  student. 

One  decided  innovation  is  the  large  number  of  authors,  nearly  every  article 
being  contributed  by  a  specialist  in  the  line  on  which  he  writes.  This,  while 
entailing  considerable  labor  upon  the  editors,  has  resulted  in  the  publication  of 
a  work  thoroughly  new  and  abreast  of  the  times. 

Especial  attention  has  been  given  to  the  latest  accepted  teachings  upon  the 
etiology,  symptoms,  pathology,  diagnosis,  and  treatment  of  the  disorders  of  chil- 
dren, with  the  introduction  of  many  special  formulae  and  therapeutic  procedures. 

Special  chapters  embrace  at  unusual  length  the  Diseases  of  the  Eye,  Ear, 
Nose  and  Throat,  and  the  Skin  ;  while  the  introductory  chapters  cover  fully  the 
important  subjects  of  Diet,  Hygiene,  Exercise,  Bathing,  and  the  Chemistry  of 
Food.  Tracheotomy,  Intubation,  Circumcision,  and  such  minor  surgical  pro- 
cedures coming  within  the  province  of  the  medical  practitioner  are  carefully 
considered. 

CONTRIBUTORS : 


Dr.  S.  S.  Adams,  Washington. 

John  Ashhurst,  Jr.,  Philadelphia. 
A.  D.  Blackader,  Montreal,  Canada. 
Dillon  Brown,  New  York. 
Edward  M.  Buckingham,  Boston. 
Charles  W.  Burr,  Philadelphia. 
W.  E.  Casselberry,  Chicago. 
Henry  Dwight  Chapin,  New  York. 
W.  S.  Christopher,  Chicago. 
Archibald  Church,  Chicago. 
Floyd  M.  Crandall,  New  York. 
Andrew  F.  Currier,  New  York. 
Roland  G.  Curtin,  Philadelphia 
J.  M.  DaCosta,  Philadelphia. 
1.  N.  Danforth,  Chicago. 
Edward  P.  Davis,  Philadelphia. 
John  B.  Deaver,  Philadelphia. 
G.  E.  de  Schweinitz,  Philadelphia. 
John  Doming,  New  York. 
Charles  Warrington  Earle,  Chicago. 
Wm.  A.  Edwards,  San  Diego,  Cal. 
F.  Forchheimer,  Cincinnati. 
J.  Henry  Fruitnight,  New  York. 
Landon  Carter  Gray,  New  York. 
J.  P.  Crozer  Grififith,  Philadelphia. 
W.  A.  Hardaway.  St.  Louis. 
M.  P    Hatfield,  Chicago. 
Barton  Cooke  Hirst,  Philadelphia. 
H.  Illoway,  Cincinnati. 
Henry  Jackson,  Boston. 
Charles  G.  Jennings,  Detroit. 
Henry  Koplik,  New  York. 


Dr.  Thomas  S.  Latimer,  Baltimore. 
Albert  R.  Leeds,  Hoboken,  N.  J. 
J.  Hendrie  Lloyd,  Philadelphia. 
George  Roe  Lockwood,  New  York. 
Henry  M.  Lyman,  Chicago. 
Francis  T.  JMiles,  Baltimore. 
Charles  K.  Mills,  Philadelphia. 
John  H.  Musser,  Philadelphia. 
Thomas  R.  Neilson,  Philadelphia. 
W.  P.  Northrup.  New  York. 
William  Osier,  Baltimore. 
Frederick  A.  Packard,  Philadelphia. 
William  Pepper,  Philadelphia. 
Frederick  Peterson,  New  York. 
W.  T.  Plant,  Syracuse,  New  York. 
William  ]\L  Powell,  Atlantic  City. 
B.  Alexander  Randall,  Philadelphia. 
Edward  O.  Shakespeare,  Philadelphia. 
F.  C.  Shattuck,  Boston. 
J.  Lewis  Smith,  New  York. 
Louis  Starr,  Philadelphia. 
M.  Allen  Starr,  New  York. 
J.  Madison  Taylor,  Philadelphia. 
Charles  W.  Townsend,  Boston. 
James  Tyson,  Philadelphia. 
W.  S.  Thayer,  Baltimore. 
Victor  C.  Vaughan,  Ann  Arbor,  Mich 
Thompson  S.  Westcolt,  Philadelphia. 
Henry  R.  Wharton,  Philadelphia. 
J.  William  White,  Philadelphia. 
J.  C.  Wilson,  Philadelphia. 


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AN  AMERICAN  TEXT-BOOK  OF  GYNECOLOGY,  MEDICAL 
AND  SURGICAL,  for  the  use  of   Students    and    Practitioners. 

Edited  by  J.  M.  Baldy,  M.  D,  Forming  a  handsome  royal-octavo  volume, 
with  360  illustrations  in  text  and  37  colored  and  half-tone  plates.  Prices : 
Cloth,  $6.00  net;  Sheep,  $7.00  net;  Half  Russia,  ^8.00  net. 

In  this  volume  all  anatomical  descriptions,  excepting  those  essential  to  a  clear 
understanding  of  the  text,  have  been  omitted,  the  illustrations  being  largely  de- 
pended upon  to  elucidate  the  anatomy  of  the  parts.  This  w^ork,  which  is 
thoroughly  practical  in  its  teachings,  is  intended,  as  its  title  implies,  to  be  a 
working  text-book  for  physicians  and  students.  A  clear  line  of  treatment  has 
been  laid  down  in  every  case,  and  although  no  attempt  has  been  made  to  dis- 
cuss mooted  points,  still  the  most  important  of  these  have  been  noted  and  ex- 
plained. The  operations  recommended  are  fully  illustrated,  so  that  the  reader, 
having  a  picture  of  the  procedure  described  in  the  text  under  his  eye,  cannot  fail 
to  grasp  the  idea.  All  extraneous  matter  and  discussions  have  been  carefully 
excluded,  the  attempt  being  made  to  allow  no  unnecessary  details  to  cumber 
the  text.  The  subject-matter  is  brought  up  to  date  at  every  point,  and  the 
work  is  as  nearly  as  possible  the  combined  opinions  of  the  ten  specialists  who 
figure  as  the  authors. 

The  work  is  well  illustrated  throughout  with  wood-cuts,  half-tone  and 
colored  plates,  mostly  selected  from  the  authors'  private  collections. 


CONTRIBrXORS : 


Vr.  Henry  T.  Byford. 
John  M.  Baldy. 
Edwin  Cragin. 
1.  H.  Etheridge. 
NViUiam  Goodell. 


Dr.  Howard  A.  Kelly. 
Florian  Krug. 
E.  E.  Montgomery. 
William  R.  Pryor. 
George  M.  Tuttle. 


"The  most  notable  contribution  to  gynecological  literature  since  1887,  ....  and  the  most 
complete  exponent  of  gynecology  which  we  have.  No  subject  seems  to  have  been  neglected, 
....  and  the  gynecologist  and  surgeon,  and  the  general  practitioner  who  has  any  desire 
to  practise  diseases  of  women,  will  find  it  of  practical  value.  In  the  matter  of  illustrations 
and  plates  the  book  surpasses  anything  we  have  seen." — Boston  Medical  and  Surgical 
yojirnal. 

"  A  valuable  addition  to  the  literature  of  Gynecology.  The  writers  are  progressive, 
aggressive,  and  earnest  in  their  convictions." — Medical  News,  Philadelphia. 

"  A  thoroughly  modern  text-book,  and  gives  reliable  and  well-tempered  advice  and  in- 
struction."— Edinburgh  Medical  Jourtial. 

"The  harmony  of  its  conclusions  and  the  homogeneity  of  its  style  give  it  an  individuality 
which  suggests  a  single  rather  than  a  multiple  authorship." — A?inals  of  Surgery. 

'•  It  must  command  attention  and  respect  as  a  worthy  representation  of  our  advanced 
clinical  teaching." — American  Journal  0/  Medical  Sciences. 


CATALOGUE   OF  MEDICAL    WORKS. 


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DISEASES  OF  THE  EYE.  A  Handbook  of  Ophthalmic  Prac- 
tice. By  G.  E.  DE  SCHWEINITZ,  M.  D.,  Professor  of  Diseases  of  the  Eye, 
Philadelphia  Polyclinic ;  Professor  of  Clinical  Ophthalmology,  Jefferson 
Medical  College,  Philadelphia,  etc.  Forming  a  handsome  royal-octavo 
volume  of  more  than  600  pages,  with  over  200  fine  wood-cuts,  many  of 
which  are  original,  and  2  chromo-lithographic  plates.  Prices :  Cloth, 
^4.00  net;  Sheep,  $5.00  net:   Half  Russia,  $5.50  net. 

The  object  of  this  work  is  to  present  to  the  student  and  practitioner  who  is 
beginning  work  in  the  fields  of  ophthalmology  a  plain  description  of  the  optical 
defects  and  diseases  of  the  eye.  To  this  end  special  attention  has  been  paid 
to  the  clinical  side  of  the  question;  and  the  method  of  examination,  the  symp- 
tomatology leading  to  a  diagnosis,  and  the  treatment  of  the  various  ocular  defects 
have  been  brought  into  special  prominence.  The  general  plan  of  the  book  is 
eminently  practical.  Attention  is  called  to  the  large  number  of  illustrations 
(nearly  one-third  of  which  are  new),  which  will  materially  facilitate  the  thorough 
understanding  of  the  subject. 

"For  the  student  and  practitioner  it  is  the  best  single  volume  at  present  published." — 
Medical  News,  Philadelphia. 

"  A  most  complete  and  sterling  presentation  of  the  present  status  of  modern  knowledge 
concerning  diseases  of  the  eye." — Medical  Age. 

"  Pre-eminently  a  book  for  those  wishing  a  clear  yet  comprehensive  and  full  knowledge 
of  the  fundamental  truths  which  imderlie  and  govern  the  practice  of  ophthalmology." — Med- 
ical and  Surgical  Reporter. 

"At  once  comprehensive  and  thoroughly  up  to  date." — Hospital  Gazette  (London). 

PROFESSIONAIi  OPINIOXS. 

"  A  work  that  will  meet  the  requirements  not  only  of  the  specialist,  but  of  the  general 
practitioner  in  a  rare  degree.     I  am  satisfied  that  unusual  success  awaits  it." 

William  Pepper,  M.  D., 
Provost  and  Professor  0/  Theory  and  Practice  of  Medicine  and  Clinical  Medicine 
in  the  University  of  Pennsylvania. 

"Contains  in  concise  and  reliable  form  the  accepted  views  of  Ophthalmic  Science." 

William  Thomson,  M.  D., 
Professor  of  Ophthalmology,  yefferson  Medical  College,  Philadelphia,  Pa. 

"  Contains  in  the  most  attractive  and  easily  understood  form  just  the  sort  of  knowledge 
which  is  necessary  to  the  intelligent  practice  of  general  medicine  and  surgery." 

J.  William  White,  M.  D., 
Professor  of  Clinical  Surgery  in  the  University  of  Pennsylvania. 

"A  very  reliable  guide  to  the  study  of  eye  diseases,  presenting  the  latest  facts  and  newest 
ideas." 

Swan  M.  Burnett,  M.  D., 

Professor  of  Ophthalmology  and  Otology,  Medical  Depart tnent  Univ.  of  Georgetown, 

IVashington,  D.  C. 


fV.   B.   SAUNDERS' 


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MEDICAL    DIAGNOSIS.      By   Dr.  Oswald  Vierordt,  Professor  of 

Medicine  at  the  University  of  Heidelberg.  Translated,  with  additions, 
from  the  Second  Enlarged  German  Edition,  with  the  author's  permission, 
by  Francis  H.  Stuart,  A.  M.,  M.  D.  Third  and  Revised  Edition.  In 
one  handsome  royal-octavo  volume  of  700  pages,  178  fine  wood-cuts  in 
text,  many  of  which  are  in  colors  Prices  :  Cloth,  $4.00  net;  Sheep,  ^5.00 
net ;   Half  Russia,  ^5.50  net. 

In  this  work,  as  in  no  other  hitherto  published,  are  given  full  and  accurate 
explanations  of  the  phenomena  observed  at  the  bedside.  It  is  distinctly  a  clin- 
ical work  by  a  master  teacher,  characterized  by  thoroughness,  fulness,  and  accu- 
racy. It  is  a  mine  of  information  upon  the  points  that  are  so  often  passed  over 
without  explanation.  Especial  attention  has  been  given  to  the  germ-theory  as 
a  factor  in  the  origin  of  disease. 

This  valuable  work  is  now  published  in  German,  English,  Russian,  and 
Italian.  The  issue  of  a  third  American  edition  within  two  years  indicates  the 
favor  with  which  it  has  been  received  by  the  profession. 

"  Rarely  is  a  book  published  with  which  a  reviewer  can  find  so  little  fault  as  with  the 
volume  before  us.  All  the  chapters  are  full,  and  leave  little  to  be  desired  by  the  reader. 
Each  particular  item  in  the  consideration  of  an  organ  or  apparatus,  which  is  necessary  to 
determine  a  diagnosis  of  any  disease  of  that  organ,  is  mentioned ;  nothing  seems  forgotten. 
The  chapters  on  diseases  of  the  circulatory  and  digestive  apparatus  and  nervous  system  are 
especially  full  and  valuable.  Notwithstanding  a  few  minor  errors  in  translating,  which  are 
of  small  importance  to  the  accuracy  of  the  rest  of  the  volume,  the  reviewer  would  repeat  that 
the  book  is  one  of  the  best— probably  the  best — which  has  fallen  into  his  hands.  An  excel- 
lent and  comprehensive  index  of  nearly  one  hundred  pages  closes  the  volume." — University 
Medical  Magazine,  Philadelphia. 

"  Thorough  and  exact The  author  has  rendered  no  mean  service  to  medicine  in 

having  prepared  a  work  which  proves  as  useful  to  the  teacher  as  to  the  student  and  prac- 
titioner."—  The  Lancet  (London).  , 

PROFESSIONAI4  OPINIONS. 

"One  of  the  most  valuable  and  useful  works  in  medical  literature." 

Aleicander  J.  C.  Skene,  M.  D., 
Dean  0/  the  Long  Island  College  Hospital,  and  Professor  of  the  Medical  and  Surgical 

Diseases  of  Wotnen. 

"  Indispensable  to  both  '  students  and  practitioners.'  " 

F.  MiNOT,  M.  D., 

Hersey  Professor  of  Theory  and  Practice  of  Medicine ,  Harvard  University. 

"  It  is  very  well  arranged  and  very  complete,  and  contains  valuable  features  not  usually 
found  in  the  ordinary  books." 

J.  H.  MussER,  M.  D., 

Assistant  Professor  Clinical  Medicine,  University  of  Pennsylvania. 

"  One  of  the  most  valuable  works  now  before  the  profession,  both  for  study  and  reference." 

N.  S.  Davis,  M.  D., 

Professor  of  Principles  and  Practice  of  Medicine  and  Clinical  Medicine,  Chicagg 

Medical  College. 


CATALOGUE   OF  MEDICAL    WORKS. 


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A  NEW  PRONOUNCING  DICTIONARY  OF  MEDICINE,  with 
Phonetic  Pronunciation,  Accentuation,  Etymology,  etc.  By  John 
M.  Keating,  M.  D.,  LL.D.,  Fellow  of  the  College  of  Physicians  of  Phila- 
delphia; Vice-President  of  the  American  Paediatric  Society;  Ex-President 
of  the  Association  of  Life  Insurance  Medical  Directors ;  Editor  "  Cyclo- 
paedia of  the  Diseases  of  Children,"  etc.;  and  Henry  Hamilton,  author 
of  "A  New  Translation  of  Virgil's  ^neid  into  English  Rhyme;"  co- 
author of  "Saunders'  Medical  Lexicon,"  etc.;  with  the  Collaboration  of 
J.  Chalmers  DaCosta,  M.  D.,  and  Frederick  A.  Packard,  M.  D. 
With  an  Appendix  containing  important  Tables  of  Bacilli,  Micrococci, 
Leucomaines,  Ptomaines,  Drugs  and  Materials  used  in  Antiseptic  Sur- 
gery, Poisons  and  their  Antidotes,  Weights  and  Measures,  Thermometric 
Scales,  New  Ofificial  and  Unofficial  Drugs,  etc.  Forming  one  very 
attractive  volume  of  over  800  pages.  Second  Revised  Edition.  Prices : 
Cloth,  ^5.00  net;  Sheep,  $6.00  net;  Half  Russia,  ^6.50  net.  With 
Denison's  Patent  Index  for  Ready  Reference. 

PROFESSIONAL.  OPINIONS. 
"  I  am  much  pleased  with  Keating's  Dictionary,  and  shall  take  pleasure  iu  recommending 
it  to  my  classes." 

Henkv  M.  Lyman,  M.  D.. 
Professor  of  Principles  and  Practice  of  Medicine,  Rush  Medical  College,  Chicago,  III. 
"  I  am  convinced  that  it  will  be  a  very  valuable  adjunct  to  my  study-table,  convenient  in 
size  and  sufficiently  full  for  ordinary  use." 

C.  A.  LiNDSLEY,  M.  D., 
Professor  of  Theory  and  Practice  of  Medicine,  Aledical  Dept.  Yale  University : 

Secretary  Connecticut  State  Board  of  Health,  New  Haven,  Conn. 
"I  will  point  out  to  my  classes  the  many  good  features  of  this  book  as  compared  with 
others,  which  will,  I  am  sure,  make  it  very  popular  with  students." 

John  Cronyn,  M.  D.,  LL.D., 
Professor  of  Principles  and  Practice  of  Medicitie  and  Clinical  Medicine  ; 

President  of  the  Faculty,  Medical  Dept.  Niagara  University,  Buffalo,  N.  Y. 

AUTOBIOGRAPHY  OF  SAMUEL  D.  GROSS,  M.  D.,  Emeritus  Pro- 
fessor of  Surgery  in  the  Jefferson  Medical  College  of  Philadelphia,  with 
Reminiscences  of  His  Times  and  Contemporaries.      Edited  by  his  sons, 
Samuel  V/.  Gross,  M.  D.,  LL.D.,  late  Professor  of  Principles  of  Surgery 
and  of  Clinical  Surgery  in  the  Jefferson  Medical  College,  and  A.  Haller 
Gross,  A.  M.,  of  the  Philadelphia  Bar.     Preceded  by  a  Memoir  of  Dr. 
Gross,  by  the  late  Austin  Flint,  AL  D.,  LL.D.     In  two  handsome  volumes, 
each  containing  over  400  pages,  demy  8vo,  extra  cloth,  gilt  tops,  with  fine 
F>ontispiece  engraved  on  steel.     Price,  $5.00  net. 
This  autobiography,  which  was  continued  by  the  late  eminent  surgeon  until 
within  three  months  of  his  death,  contains  a  full  and  accurate  history  of  his 
early  struggles,  trials,  and  subsequent  successes,  told  in  a  singularly  interesting 
and  charming  manner,  and  embraces  short  and  graphic  pen-portraits  of  many 
of  the  most  distinguished  men — surgeons,  physicians,  divines,  lawyers,  states- 
men, scientists,  etc. — with  whom  he  was  brought  in  contact  in  America  and  in 
Europe  ;  the  whole  forming  a  retrospect  of  more  than  three-quarters  of  a  century. 


W.   B.   SAUNDERS' 


For  Sale  by  Subscription. 


AN  AMERICAN  TEXT-BOOK  OF  OBSTETRICS.  By  American 
Teachers.  By  Richard  C.  Norris,  A.  M.,  M.  D.;  James  H.  Etheridge, 
M.  D. ;  Chauncey  D.  Palmer.  M.  D. ;  Howard  A.  Kelly,  M.  D. ;  Charles 
Jewett,  M.  D. ;  Henry  J.  Garrigues,  M.  D. ;  Barton  Cooke  Hirst,  M.  D. ; 
Theophilus  Parvin,  M.  D. ;  George  A.  Piersol,  M.  D. ;  Edward  P.  Davis, 
M.  D. ;  Charles  Warrington  Earle,  M.  D. ;  Robert  L.  Dickinson,  M.  D. ; 
Edward  Reynolds,  M.  D. ;  Henry  Schwarz,  M.  D. ;  and  James  C.  Cam- 
eron, M.  D.  In  one  very  handsome  imperial- octavo  volume,  with  a  large 
number  of  original  illustrations,  including  full-page  plates,  and  uniform 
with  "  The  American  Text-Book  of  Gynecology."    (In  active  preparation.) 

Such  an  array  of  well-known  teachers  is  a  sufficient  guarantee  of  the  high 
character  of  the  work,  and  it  gives  the  assurance  that  this  work  will  have  the 
same  measure  of  success  awarded  it  as  has  attended  the  recent  publication  of 
its  companion  volume,  "  The  American  Text-Book  of  Gynecology."  The  illus- 
trations will  receive  the  most  minute  attention  ;  the  cuts  interspersed  throughout 
the  text,  and  the  full-page  plates,  which  will  reflect  the  highest  attainments  of 
the  artist  and  engraver,  will  appeal  at  once  to  the  eye  as  well  as  to  the  mind 
of  the  student  and  practitioner. 

AN  AMERICAN  TEXT-BOOK  OF  PHYSIOLOGY.     By  American 

Teachers.  Edited  by  William  H.  Howell,  Ph.  D.,  INI.  D.,  Professor, 
of  Physiology,  Johns  Hopkins  University.  With  the  collaboration  of  such 
eminent  specialists  as  Henry  P.  Bowditch,  M.  D. ;  John  G.  Curtis,  M.  D. ; 
Henry  H.  Donaldson,  M.  D. ;  Frederick  S.  Lee,  M.  D. ;  Warren  P.  Lom- 
bard, A.  B.,  M.  D. ;  Graham  Lusk,  Ph.  D.  ;  Henry  Sewall,  M.  D. ;  Edward 
T.  Reichert,  M.  D. ;  Joseph  W.  Warren,  M.  D.  In  one  imperial-octavo 
volume  (with  a  large  number  of  original  illustrations),  \iniform  with  The 
American  Text-Books  of  "  Surgery,"  "  Practice,"  "  Gynecology,"  etc. 
(In  preparation  for  early  publication.) 

This  will  be  the  most  notable  attempt  yet  made  in  this  country  to  combine  in 
one  volume  the  entire  subject  of  Human  Physiology  by  well-known  teachers 
who  have  given  especial  study  to  that  part  of  the  subject  upon  which  they  will 
write.  The  completed  work  will  represent  the  present  status  of  the  science  of 
Physiology,  and  in  particular  from  the  standpoint  of  the  student  of  medicine 
and  the  medical  practitioner.  Illustrations  largely  drawn  from  original  sources 
will  be  used  freely  throughout  the  text. 

AN  AMERICAN  TEXT-BOOK  OF  APPLIED  THERAPEUTICS. 

By  American  Teachers.     (In  preparation.) 

AN    AMERICAN    TEXT-BOOK   OF   NURSING.      By   American 
Teachers.     (In  preparation.) 


CATALOGUE   OF  MEDICAL    WORKS. 


A  SYLLABUS  OF  GYNiECOLOGY,  arranged  in  conformity  with 
The  American  Text-Book  of  Gynecology.  By  J.  W.  Long,  M.  D., 
Professor  of  Diseases  of  Women  and  Children,  Medical  College  of  Vir- 
ginia, etc.     Price,  Cloth  (interleaved),  ^i.oo  net. 

Based  upon  the  teaching  and  methods  laid  down  in  the  larger  work,  this  will 
not  only  be  useful  as  a  supplementary  volume,  but  to  those  who  do  not  already 
possess  the  text-book  it  will  also  have  an  independent  value  as  an  aid  to  the 
practitioner  in  gynecological  work,  and  to  the  student  as  a  guide  in  the  lecture- 
room,  as  the  subject  is  presented  in  a  manner  at  once  systematic,  clear,  succinct, 
and  practical. 


TEMPERATURE   CHART.     Prepared  by  D.  T.  Laine,  M.  D.      Size 
8x  13  j^  inches.     Price,  per  pad  of  25  charts,  50  cents. 

A  conveniently  arranged  chart  for  recording  Temperature,  with  columns  for 
daily  amounts  of  Urinary  and  Fecal  Excretions,  Food,  Remarks,  etc.  On  the 
back  of  each  chart  is  given  in  full  the  method  of  Brand  in  the  treatment  of 
Typhoid  Fever. 


THE  NURSE'S  DICTIONARY  of  Medical  Terms  and  Nursing 
Treatment,  containing  Definitions  of  the  Principal  Medical  and  Nursing 
Terms,  Abbreviations,  and  Physiological  Names,  and  Descriptions  of  the 
Instruments,  Drugs,  Diseases,  Accidents,  Treatments,  Operations,  Foods, 
Appliances,  etc.  encountered  in  the  ward  or  in  the  sick-room.  Compiled 
for  the  use  of  nurses.  By  HoNNOR  Morten,  author  of  "  How  to  Become 
a  Nurse,"  "  Sketches  of  Hospital  Life,"  etc.  Second  and  enlarged  edi- 
tion.    i6mo,  140  pages.     Price,  Cloth,  $1.00. 

This  little  volume  is  intended  for  use  merely  as  a  small  reference-book  which 
can  be  consulted  at  the  bedside  or  in  the  ward.  It  gives  sufficient  explanation 
to  the  nurse  to  enable  her  to  comprehend  a  case  until  she  has  leisure  to  look 
up  larger  and  fuller  works  on  the  subject. 

"Should  be  at  the  disposal  of  every  nurse." — Birmingham  Medical  Review. 

"Maintains  its  reputation  for  brevity  and  simplicity." — Hahnetizannian  Monthly. 

"Though  ostensibly  for  professional  nurses,  contains  in  a  compact  form  just  such  infor- 
mation as  almost  every  intelligent  man  would  like  to  have  at  hand  in  these  days  when 
the  interest  in  all  matters  of  sanitation  and  medicine  has  become  so  great." — Medical 
Examiner. 

"  A  book  which  every  progressive  nurse  must  have." — Medical  IVorld. 

"  This  little  volume  is  almost  indispensable  in  the  training  school  and  in  the  library  of  the 
nurse." — New  York  Medical  Times. 


10  W.   B.   SAUNDERS' 


SURGICAL  PATHOLOGY  AND  THERAPEUTICS.  By  J.  Col- 
lins Warren,  M.  D.,  Professor  of  Surgery,  Harvard  Medical  School,  etc. 
In  one  very  handsome  octavo  volume  of  over  800  pages,  with  135  illus- 
trations, 2)3  of  which  are  chromo-lithographs,  and  all  of  which  are  drawn 
from  original  specimens.  Prices:  Cloth,  ^6.00  net ;  Half  Morocco,  $7.00 
net.     Sold  by  subscription. 

Covering  as  it  does  the  entire  field  of  Surgical  Pathology  and  Surgical  Thera- 
peutics by  an  acknowledged  authority,  the  publisher  is  confident  that  the  work 
will  rank  as  a  standard  authority  on  the  subject  of  which  it  treats.  Particular 
attention  has  been  paid  to  Bacteriology  and  Surgical  Bacteria  from  the  stand- 
point of  recent  investigations,  and  the  chromo-lithographic  plates  in  their  fidelity 
to  nature  and  in  scientific  accuracy  have  hitherto  been  unapproached. 

DISEASES  OF  WOMEN.  By  Henry  J.  Garrigues,  A.M.,  M.D., 
Professor  of  Obstetrics  in  the  New  York  Post-Graduate  Medical  School 
and  Hospital; -Gynecologist  to  St.  Mark's  Hospital  and  to  the  German 
Dispensary,  etc.,  New  York  City.  In  one  very  handsome  octavo  volume 
of  about  700  pages,  illustrated  by  numerous  wood-cuts  and  colored  plates. 
Prices:  Cloth,  $4.00  net;   Sheep,  ^5.00  net. 

A  practical  work  on  gynecology  for  the  use  of  students  and  practitioners, 
written  in  a  terse  and  concise  manner.  The  importance  of  a  thorough  know- 
ledge of  the  anatomy  of  the  female  pelvic  organs  has  been  fully  recognized  by 
the  author,  and  considerable  space  has  been  devoted  to  the  subject.  The  chap- 
ters on  Operations  and  on  Treatment  are  thoroughly  modern,  and  are  based 
upon  the  lai'ge  hospital  and  private  practice  of  the  author.  The  text  is  eluci- 
dated by  a  large  number  of  illustrations  and  colored  plates,  many  of  them  being 
original,  and  forming  a  complete  atlas  for  studying  emb^'yology  and  the  anatomy 
of  \.h.Q  fe?nale  genitalia,  besides  exemplifying,  whenever  needed,  morbid  condi- 
tions, instruments,  apparatus,  and  operations. 

EXCERPT   OF   COJTTENTS. 

Development  of  the  Female  Genitals.— Anatomy  of  the  Female  Pelvic  Organs.— Phys- 
iology.—Puberty.— Menstruation  and  Ovulation.— Copulation.— Fecundation.— The  Climac- 
teric.— Etiology  in  General. — Examinations  in  General. — Treatment  in  General — Abnormal 
Menstruation  and  Metrorrhagia. — Leucorrhea. — Diseases  of  the  Vulva. — Diseases  of  the 
Perineum. — Diseases  of  the  Vagina. — Diseases  of  the  Uterus. — Diseases  of  the  Fallopian 
Tubes. — Diseases  of  the  Ovaries. — Diseases  of  the  Pelvis. — Sterility. 

The  reception  accorded  to  this  work  has  been  most  flattering.  In  the  short 
period  which  has  elapsed  since  its  issue  it  has  been  adopted  and  recommended 
as  a  text-book  by  more  than  60  of  the  Medical  Schools  and  Universities  of  the 
United  States  and  Canada. 

"One  of  the  best  text-books  for  students  and  practitioners  which  has  been  puhlished  in 
the  English  language;  it  is  condensed,  clear,  and  comprehensive.  The  profound  learning 
and  great  clinical  experience  of  the  distinguished  aiuhor  find  expression  in  this  book  in  a 
most  attractive  and  instructive  form.  Young  practitioners,  to  whom  experienced  consultants 
-niay  not  be  available,  will  find  in  this  book  invaluable  counsel  and  help." 

Thad.  a.  Reamy,  M.  D.,  LL.D., 
Professor  0/  Clinical  Gynecology ,  Medical  CoUef^e  of  Ohio  ;  Gynecologist  to  the  Good 

Samaritan  and  Cincinnati  Hospitals. 


Practical,  Exhaustive,  Autl)oritative. 


SAUNDERS' 

NEW  AID  SERIES  OF  MANUALS 


FOR 


Students  and  Practitioners. 


Mr.  Saunders  is  pleased  to  announce  as  in  active  preparation  his  NEW 
AID  SERIES  OF  MANUALS  for  Students  and  Practitioners.  As 
publisher  of  the  Standard  Series  of  Question  Compends,  and  through  in- 
timate relations  with  leading  members  of  the  medical  profession,  Mr.  Saunders 
has  been  enabled  to  study  progressively  the  essential  desiderata  in  practical 
"self-helps"  for  students  and  physicians. 

This  study  has  manifested  that,  while  the  published  "  Question  Compends" 
earn  the  highest  appreciation  of  students,  whom  they  serve  in  reviewing  their 
studies  preparatory  to  examination,  there  is  special  need  of  thoroughly  reliable 
handbooks  on  the  leading  branches  of  Medicine  and  Surgery,  each  subject 
being  compactly  and  authoritatively  written,  and  exhaustive  in  detail,  without 
the  introduction  of  cases  and  foreign  subject-matter  which  so  largely  expand 
ordinary  text-books. 

The  Saunders  Aid  Series  will  not  merely  be  condensations  from 
present  literature,  but  will  be  ably  written  by  well-known  authors 
and  practitioners,  most  of  them  being  teachers  in  representative 
American  Colleges.  This  nero  series^  therefore,  will  form  an  admirable 
collection  of  advanced  lectures,  which  will  be  invaluable  aids  to  students  in 
reading  and  in  comprehending  the  contents  of  "  recommended  "  works. 

Each  Manual  will  further  be  distinguished  by  the  beauty  of  the  new  type ; 

by  the  quality  of  the  paper  and  printing;  by  the  copious  use  of  illustrations; 

by  the  attractive  binding  in  cloth ;  and  by  the  extremely  low  price,  which 

will  uniformly  be  $1.25  per  volume. 

II 


SAUNDERS'  NEW  AID  SERIES  OF  MANUALS. 


VOLUMES  NOW  EEADY. 


PHYSIOLOGY.  By  Joseph  Howard  Raymond,  A.M.,  M.  D.,  Professor 
of   Physiology  and  Hygiene  and  Lecturer  on  Gynecology  in  the  Long 

Island  College  Hospital,  etc.     Price,  ^1.25  net. 

SURGERY,  General  and  Operative.  By  John  Chalmers  DaCosta, 
M.  D,,  Demonstrator  of  Surgery,  Jefferson  Medical  College,  Philadelphia, 
etc.     Double  number.     Price,  $2.50  net. 

DOSE-BOOK  AND  MANUAL  OF  PRESCRIPTION-WRITING. 

By  E.  Q.  Thornton,   M.  D.,  Demonstrator  of  Therapeutics,  Jefferson 

Medical  College,  Philadelphia,     Price,  ^1.25  net. 

MEDICAL  JURISPRUDENCE.  By  Henry  C.  Chapman,  M.  D.,  Pro- 
fessor of  Institutes  of  Medicine  and  Medical  Jurisprudence  in  the  Jeffer- 
son Medical  College  of  Philadelphia,  etc.     Price,  ^1.25  net. 

SURGICAL  ASEPSIS.  By  Carl  Beck,  M.D.,  Surgeon  to  St.  Mark's 
Hospital  and  to  the  German  Poliklinik ;  Instructor  in  Surgery,  New  York 
Post-Graduate  Medical  School,  etc.     Price,  $1.25  net. 


VOLUMES  IN  PEEPAEATION  FOR  EAELY  PUBLICATION. 

OBSTETRICS.  By  W.  A.  Newman  Dorland,  M.  D.,  Demonstrator  of 
Obstetrics,  University  of  Pennsylvania;  Chief  of  Gynecological  Dispen- 
sary, Pennsylvania  Hospital ;  Member  of  Philadelphia  Obstetrical  Society, 
etc.     Price,  ^1.25  net. 

MATERIA    MEDICA    AND    THERAPEUTICS.      By    Henry   A. 

Griffin,   A.  B.,  M.  D.,  Assistant   Physician   to  tlie   Roosevelt   Hospital, 
Out-patient  Department,  New  York  City.     Price,  ^1.25  net. 

SYPHILIS  AND  THE  VENEREAL  DISEASES.  By  James 
Nevins  Hyde,  M.  D.,  Professor  of  Skin  and  Venereal  Diseases  in  Rush 
Medical  College,  Chicago.     Double  number.     Price,  ^2.50  net. 

NERVOUS  DISEASES.  By  Charles  W.  Burr,  M.  D.,  Clinical  Pro- 
fessor of  Nervous  Diseases,  Medico-Chirurgical  College,  Philadelphia, 
etc.     Price,  ^1.25  net. 

PRACTICE  OF  MEDICINE.  By  George  Roe  Lockwood,  M.  D., 
Professor  of  Practice  in  the  Woman's  Medical  College  and  in  the  New 
York  Infirmary,  etc.     Double  number.     Price,  $2.50  net. 

NOSE  AND  THROAT.  By  D.  Braden  Kyle,  M.  D.,  Chief  Laryngol- 
ogist  to  St.  Agnes'  Hospital,  Philadelphia;  Instructor  in  Clinical  Micros- 
copy and  Assistant  Demonstrator  of  Pathology  in  the  Jefferson  Medical 
College,  etc.     Price,  ^1.25  net. 

*.,.*  There  will  be  published  in  the  same  series,  at  close  intervals,  carefully-pre- 
pared works  on  the  subjects  of  Anatomy,  Gynecology,  Pathology,  Hygiene,  etc., 
by  prominent  specialists. 
12 


CATALOGUE    OF  MEDICAL    WORKS.  1 3 

Saunders'  New  Aid  Series  of  Manuals, 


A  MANUAL  OF  PHYSIOLOGY.  By  Joseph  H.  Raymond,  A.  M., 
M.D.,  Professor  of  Physiology  and  Hygiene  and  Lecturer  on  Gynecology 
in  the  Long  Island  College  Hospital ;  Director  of  Physiology  in  the  Hoag- 
land  Laboratory;  formerly  Lecturer  on  Physiology  and  Hygiene  in  the 
Brooklyn  Normal  School  for  Physical  Education;  Ex-Vice-President  of 
the  American  Public  Health  Association ;  Ex-Health  Commissioner  City 
of  Brooklyn,  etc.     Illustrated.     Price,  Cloth,  $1.25  net.     (Just  ready.) 

In  this  manual  the  author  has  endeavored  to  put  into  a  concrete  and  avail- 
able form  the  results  of  twenty  years'  experience  as  a  teacher  of  Physiology  to 
medical  students,  and  has  produced  a  work  for  the  student  and  practitioner, 
representing  in  a  concise  fomi  the  existing  state  of  Physiology  and  its  methods 
of  investigation,  based  upon  Comparative  and  Pathological  Anatomy,  Clinical 
Medicine,  Physics,  and  Chemistry,  as  well  as  upon  experimental  research. 


MANUAL  OF  SURGERY,  General  and  Operative.  By  John 
Chalmers  DaCosta,  M.  D.,  Demonstrator  of  Surgery,  Jefferson  Medical 
College,  Philadelphia;  Chief  Assistant  Surgeon,  JeiTerson  Medical  College 
Hospital ;  Surgical  Registrar,  Philadelphia  Hospital,  etc.  One  very  hand- 
some volume  of  over  700  pages,  with  a  large  number  of  illustrations. 
(Double  number.)     Price,  Cloth,  ^2.50  net. 


A  new  manual  of  the  Principles  and  Practice  of  Surgery,  intended  to  meet 
the  demands  of  students  and  working  practitioners  for  a  medium-sized  work 
which  w411  embody  all  the  newer  methods  of  procedure  detailed  in  the  larger 
text-books.  The  work  has  been  written  in  a  concise,  practical  manner,  and 
especial  attention  has  been  given  to  the  most  recent  methods  of  treatment. 
Illustrations  are  freely  used  to  elucidate  the  text. 


A  MANUAL  OF  OBSTETRICS.  By  W.  A.  Newman  Dorland, 
M.  D.,  Demonstrator  of  Obstetrics,  University  of  Pennsylvania;  Chief  of 
Gynecological  Dispensary,  Pennsylvania  Hospital ;  Member  of  Phila- 
delphia Obstetrical  Society,  etc.  Profusely  illustrated.  Price,  Cloth^ 
^1.25  net.     (Preparing.) 

This  work,  which  is  thoroughly  practical  in  its  teachings,  is  intended,  as  its 
title  implies,  to  be  a  working  text-book  for  the  student  and  of  value  to  the 
practitioner  as  a  convenient  handbook  of  reference.  Although  concisely  writ- 
ten, nothing  of  importance  is  omitted  that  will  give  a  clear  and  succinct  know- 
ledge of  the  subject  as  it  stands  to-day.  Illustrations  are  freely  used  throughout 
the  text. 


14  W.   B.    SAUNDERS' 


Saunders'  JVeiv  Aid  Series  of  Manuals, 


DOSE-BOOK  AND  MANUAL  OF  PRESCRIPTION-WRITING. 

By  E.  Q.  Thornton,  M.  D.,  Demonstrator  of  Therapeutics,  Jefferson 
Medical  College,  Philadelphia.     Illustrated.     Price,  Cloth,  $1.25  net. 

But  little  attention  is  generally  given,  in  works  on  Materia  Medica  and  Thera- 
peutics, to  the  methods  of  combining  remedies  in  the  form  of  prescriptions,  and 
this  manual  has  been  written  especially  for  students  in  the  hope  that  it  may 
sen-e  to  give  a  thorough  and  comprehensive  knowledge  of  the  subject. 

The  work,  which  is  based  upon  the  last  (1890)  edition  of  the  Pharmacopceia, 
fully  covers  the  subjects  of  Weights  and  Measures,  Prescriptions  (form  of 
writing,  general  directions  to  pharmacist,  grammatical  construction,  etc.), 
Dosage,  Incompatibles,  Poisons,  etc. 

MEDICAL  JURISPRUDENCE  AND  TOXICOLOGY.     By  Henry 

C.  Chapman,  M.  D.,  Professor  of  Institutes  of  Medicine  and  Medical 
Jurisprudence  in  the  Jefferson  Medical  College  of  Philadelphia ;  Member 
of  the  College  of  Physicians  of  Philadelphia,  of  the  Academy  of  Natural 
Sciences  of  Philadelphia,  of  the  American  Philosophical  Society,  and  of 
the  Zoological  Society  of  Philadelphia.  232  pages,  with  36  illustrations, 
some  of  which  are  in  colors.     Price,  ^1.25  net. 

For  many  years  there  has  been  a  demand  from  members  of  the  medical  and 
legal  professions  for  a  medium-sized  work  on  this  most  important  branch  of 
medicine.  The  necessarily  proscribed  limits  of  the  work  permit  the  considera- 
tion only  of  those  parts  of  this  extensive  subject  which  the  experience  of  the 
author  as  coroner's  physician  of  the  city  of  Philadelphia  for  a  period  of  six 
years  leads  him  to  regard  as  the  most  material  for  practical  purposes. 

Particular  attention  is  drawn  to  the  illustrations,  many  being  produced  in 
colors,  thus  conveying  to  the  layman  a  far  clearer  idea  of  the  more  intricate 
cases. 

SURGICAL  ASEPSIS.  By  Carl  Beck,  M.  D.,  Surgeon  to  St.  Mark's 
Hospital  and  to  the  New  York  German  Polikhnik,  etc.  Price,  Cloth, 
$1.25  net. 

A  practical  work  for  the  study  of  the  principles  of  Surgical  Asepsis.  Hand- 
somely embellished  with  nearly  loo  graphic  representations  of  methods  and 
appliances. 


A  GUIDE  TO  THE  BACTERIOLOGICAL  LABORATORY.     By 
Langdon  Frothin(;ham,  M.D.     Illustrated.     Price,  75  cents. 

The  technical  methods  involved  in  bacteria-culture,  methods  of  staining,  and 
microscopical  study  are  fully  described  and  arranged  as  simply  and  concisely 
as  possible.     The  book  is  especially  intended  for  u.se  in  laboratory  work. 


CATALOGUE    OF  MEDICAL    WORKS.  1 5 


NURSING:  ITS  PRINCIPLES  AND  PRACTICE.  By  Isabel 
Adams  Hampton,  Graduate  of  the  New  York  Training  School  for 
Nurses  attached  to  Bellevue  Hospital ;  Superintendent  of  Nurses  and 
Principal  of  the  Training  School  for  Nurses,  Johns  Hopkins  Hospital, 
Baltimore,  Md. ;  late  Superintendent  of  Nurses,  Illinois  Training  School 
for  Nurses,  Chicago,  111.  In  one  very  handsome  i2mo  volume  of  484 
pages,  profusely  illustrated.     Price,  Cloth,  $2.00  net. 

This  entirely  new  work  on  the  important  subject  of  nursing  is  at  once  com- 
prehensive and  systematic.  It  is  written  in  a  clear,  accurate,  and  readable 
style,  suitable  alike  to  the  student  and  the  lay  reader.  Such  a  work  has  long 
been  a  desideratum  with  those  intrusted  with  the  management  of  hospitals  and 
the  instruction  of  nurses  in  training  schools.  It  is  also  of  especial  value  to  the 
graduated  nurse  who  desires  to  acquire  a  practical  working  knowledge  of  the 
care  of  the  sick  and  the  hygiene  of  the  sick-room. 

The  author,  who  has  had  considerable  experience  as  superintendent  of 
training  schools  for  nurses  and  hospital  management,  bnngs  to  her  task  a  mind 
thoroughly  equipped  to  make  the  subject  attractive  as  well  as  scientific  and 
instructive. 

Thoroughly  attested  and  approved  processes  in  practical  nursing  only  have 
been  given,  particularly  in  antiseptic  surgery,  and  the  minutest  details  regard- 
ing the  nurse's  technique  have  been  explained. 

Illustrations  to  elucidate  the  text  have  been  used  freely  throughout  the  book, 
and  they  will  be  found  of  material  help  m  showing  the  forms  of  modern  appli- 
ances for  the  hospital  ward  and  sick-room,  the  registration  of  temperature,  daily 
records,  etc. 


METHODS  OF  PREVENTING  AND  CORRECTING  DEFORM- 
ITIES OF  THE  BONES  AND  JOINTS  :  A  Handbook  of  Prac- 
tical Orthopedic  Surgery.  By  H.  Augustus  Wilson,  M.  D  ,  Professor 
of  General  and  Orthopedic  Surgery,  Philadelphia  Polyclinic ;  Clinical  Pro- 
fessor of  Orthopedic  Surgery,  Jefferson  Medical  College,  Philadelphia,  etc. 
(In  preparation.) 

The  aim  of  the  author  is  to  provide  a  book  of  moderate  size,  containing 
comprehensive  details  that  will  enable  general  practitioners  to  understand  thor- 
oughly the  mechanical  features  of  the  many  forms  of  congenital  and  acquired 
deformities  of  the  bones  and  joints. 

The  mechanical  functions  that  are  impaired  will  be  considered  first  as  to  pre- 
vention as  of  primary  importance,  and  following  this  will  be  described  the 
methods  of  correction  that  have  been  proved  practical  by  the  author.  Ope- 
rative procedures  will  be  considered  from  a  mechanical  as  well  as  a  surgical 
standpoint.  Prominence  will  be  given  to  the  mechanical  requirements  for 
braces  and  artificial  limbs,  etc.,  with  description  of  the  methods  for  construct- 
ing the  simplest  forms,  whether  made  of  plaster  of  Paris,  felt,  leather,  paper, 
steel,  or  other  materials,  together  with  the  methods  of  readjustment  to  suit  the 
changes  occurring  during  the  progress  of  the  case.  A  very  large  number  of 
original  illustrations  will  be  used. 


1 6  IV.   B.    SAUNDERS' 


AN  OPERATION  BLANK,  with  Lists  of  Instruments,  etc.  re- 
quired in  Various  Operations.  Prepared  by  W.  W.  Keen,  M.  D., 
LL.D.,  Professor  of  Principles  of  Surgery  in  the  Jefferson  Medical  Col- 
lege, Philadelphia.  Price  per  Pad,  containing  Blanks  for  fifty  operations, 
50  cents  net. 

A  convenient  blank,  suitable  for  all  operations,  giving  complete  instructions 
regarding  necessary  preparation  of  patient,  etc.,  with  a  full  list  of  dressings  and 
medicines  to  be  employed. 

At  the  back  of  pad  is  a  list  of  instruments  used — viz.  general  instruments, 
etc.,  required  for  all  operations;  and  special  nistruments  for  surgery  of  the 
brain  and  spme,  mouth  and  throat,  abdomen,  rectum,  male  and  female  genito- 
urinary organs,  the  bones,  etc. 

The  whole  forming  a  neat  pad,  arranged  for  hanging  on  the  wall  of  a  sur- 
geon's office  or  in  the  hospital  operatmg-room. 

"  Will  serve  a  useful  purpose  for  the  surgeon  in  reminding  him  of  the  details  of  prepa- 
ration for  the  patient  and  the  room  as  well  as  for  the  instruments,  dressings,  and  antiseptics 
needed  " — Ne-jj  York  Medical  Record 

"  Covers  about  all  that  can  be  needed  in  any  operation." — American  Lancet. 

"  The  plan  is  Si  capital  one."— Bosion  Medical  and  Surgical  Journal. 


ESSENTIALS  OF  ANATOMY  AND  MANUAL  OF  PRACTI- 
CAL DISSECTION,  containing  "  Hints  on  Dissection  "  By  Charles 
B.  Nancrede,  M.  D.,  Professor  of  Surgery  and  Clinical  Surgery  in  the 
University  of  Michigan,  Ann  Arbor;  Corresponding  Member  of  the  Royal 
Academy  of  Medicine,  Rome,  Italy;  late  Surgeon  Jefferson  Medical  Col- 
lege, etc.  Fourth  and  revised  edition.  Post  8vo,  over  500  pages,  with 
handsome  full-page  lithographic  plates  in  colors,  and  over  200  illustrations. 
Price  :  Extra  Cloth  or  Oilcloth  for  the  dissection-room,  $2.00  net. 

Neither  pains  nor  expense  has  been  spared  to  make  this  work  the  most  ex- 
haustive yet  concise  Student's  Manual  of  Anatomy  and  Dissection  ever  pub- 
lished, either  in  America  or  in  Europe. 

The  colored  plates  are  designed  to  aid  the  student  in  dissecting  the  muscles, 
arteries,  veins,  and  nerves.  The  wood-cuts  have  all  been  specially  drawn  and 
engraved,  and  an  Appendix  added  containing  60  illustrations  representing  the 
structure  of  the  entire  human  skeleton,  the  whole  being  based  on  the  eleventh 
edition  of  Gray's  Anatomy^  and  forming  a  handsome  post  8vo  volume  of  over 
500  pages. 

"  The  plates  are  of  more  than  ordinary  excellence,  and  are  of  especial  value  to  students  in 
their  work  in  the  C^\'T,'=,itz\\x\%-xouxv\"— Journal  of  American  Medical  Association. 

"  Should  be  in  the  hands  of  every  medical  student." — Cleveland  Medical  Gazette. 

"  A  concise  and  judicious  ^oxV."— Buffalo  Medical  and  Surgical  Journal. 


CATALOGUE    OF  MEDICAL    WORKS.  1/ 


A  MANUAL  OF  PRACTICE  OF  MEDICINE.  By  A.  A.  Stevens, 
A.  M,,  M.  D.,  Instructor  of  Physical  Diagnosis  in  the  University  of  Penn- 
sylvania, and  Demonstrator  of  Pathology  in  the  Woman's  Medical  College 
of  Philadelphia.  Specially  intended  for  students  preparing  for  graduation 
and  hospital  examinations,  and  includes  the  following  sections :  General 
Diseases,  Diseases  of  the  Digestive  Organs,  Diseases  of  the  Respirator)' 
System,  Diseases  of  the  Circulatory  System,  Diseases  of  the  Nervous  Sys- 
tem, Diseases  of  the  Blood,  Diseases  of  the  Kidneys,  and  Diseases  of  the 
Skin.  Each  section  is  prefaced  by  a  chapter  on  General  Symptomatology. 
Third  edition.  Post  8vo,  502  pages.  Numerous  illustrations  and  selected 
formulae.     Price,  ^2.50. 

Contributions  to  the  science  of  medicine  have  poured  in  so  rapidly  during  the 
^ast  quarter  of  a  century  that  it  is  well-nigh  impossible  for  the  student,  with  the 
limited  time  at  his  disposal,  to  master  elaborate  treatises  or  to  cull  from  them 
that  knowledge  which  is  absolutely  essential.  From  an  extended  experience  in 
teaching,  the  author  has  been  enabled,  by  classification,  to  group  allied  symp- 
toms, and  by  the  judicious  elimination  of  theories  and  redundant  explanations 
to  bring  within  a  comparatively  small  compass  a  complete  outline  of  the  prac- 
tice of  medicine. 

A  SYLLABUS  OF  LECTURES  ON  THE  PRACTICE  OF  SUR- 
GERY, arranged  in  conformity  with  The  American  Text-Book  of 
Surgery.  By  Nicholas  Senn,  M.  D.,  Ph.  D.,  Professor  of  Surgery  in 
Rush  Medical  College,  Chicago,  and  in  the  Chicago  Polyclinic.  Price, 
^2.00. 

This,  the  latest  work  of  its  eminent  author,  himself  one  of  the  contributors 
to  the  "  American  Text- Book  of  Surgery,"  will  prove  of  exceptional  value  to 
the  advanced  student  who  has  adopted  that  work  as  his  text-book.  It  is  not 
only  the  syllabus  of  an  unrivalled  course  of  surgical  practice,  but  it  is  also  an 
epitome  or  supplement  to  the  larger  work. 

SYLLABUS  OF  OBSTETRICAL  LECTURES  in  the  Medical 
Department,  University  of  Pennsylvania.  By  Richard  C.  Norris, 
A.  M.,  M.  D.,  Demonstrator  of  Obstetrics  in  the  University  of  Pennsyl- 
vania. Third  edition,  thoroughly  revised  and  enlarged.  Crown  8vo. 
Price,  Cloth,  interleaved  for  notes,  $2.00  net. 

"This  work  is  so  far  superior  to  others  on  the  same  subject  that  we  take  pleasure  in  call- 
ing attention  briefly  to  its  excellent  features.  It  covers  the  subject  thoroughly,  and  will 
prove  invaluable  both  to  the  student  and  the  practitioner.  The  author  has  introduced  a 
number  of  valuable  hints  which  would  only  occur  to  one  who  was  himself  an  experienced 
teacher  of  obstetrics.  The  subject-matter  is  clear,  forcible,  and  modern.  We  are  especially 
pleased  with  the  portion  devoted  to  the  practical  duties  of  the  accoucheur,  care  of  the  child, 
etc.  The  paragraphs  on  antiseptics  are  admirable;  there  is  no  doubtful  tone  in  the  direc- 
tions given.  No  details  are  regarded  as  unimportant;  no  minor  matters  omitted.  We  ven- 
ture to  say  that  even  the  old  practitioner  will  find  useful  hints  in  this  direction  which  he  can- 
not afford  to  despise." — Neiv  York  Medical  Record. 


1 8  W.   B.    SAUNDERS' 


OUTLINES  OF  OBSTETRICS  :  A  Syllabus  of  Lectures  Deliv- 
ered at  Long  Island  College  Hospital.  By  Charles  Jewett,  A.  M,, 
M.  D.,  Professor  of  Obstetrics  and  Pediatrics  in  the  College,  and  Obstetri- 
cian to  the  Hospital.  Edited  by  Harold  F.  Jewett,  jSI.  D.  Post  8vo, 
264  pages.     Price,  $2.00. 

This  book  treats  only  of.  the  general  facts  and  principles  of  obstetrics  :  these 
are  stated  in  concise  terms  and  in  a  systematic  and  natural  order  of  sequence, 
theoretical  discussion  being  as  far  as  possible  avoided;  the  subject  is  thus 
presented  in  a  form  most  easily  grasped  and  remembered  by  the  student. 
Special  attention  has  been  devoted  to  practical  questions  of  diagnosis  and 
treatment,  and  in  general  particular  prominence  is  given  to  facts  which  the  stu- 
dent most  needs  to  know.  The  condensed  form  of  statement  and  the  orderly 
arrangement  of  topics  adapt  it  to  the  wants  of  the  busy  practitioner  as  a  means 
of  refreshing  his  knowledge  of  the  subject  and  as  a  handy  manual  for  daily 
reference. 


NOTES  ON  THE  NEWER  REMEDIES:  their  Therapeutic  Ap- 
plications and  Modes  of  Administration.  By  David  Cerna,  M.  D., 
Ph.  D.,  Demonstrator  of  and  Lecturer  on  Experimental  Therapeutics  in 
the  University  of  Pennsylvania.     Post-octavo,  253  pages.     Price,  ^1.25. 

The  work  takes  up  in  alphabetical  order  all  the  newer  remedies,  giving  their 
physical  properties,  solubility,  therapeutic  applications,  administration,  and 
chemical  formula. 

It  thus  forms  a  very  valuable  addition  to  the  various  works  on  therapeutics 
now  in  existence. 

Chemists  are  so  multiplying  compounds,  that,  if  each  compound  is  to  be  thor- 
oughly studied,  investigations  must  be  carried  far  enough  to  determine  the  prac- 
tical importance  of  the  new  agents. 

"  Especially  valuable  because  of  its  completeness,  its  accuracy,  its  systematic  consider- 
ation of  the  properties  and  therapy  of  many  remedies  of  which  doctors  generally  know  but 
little,  expressed  in  a  brief  yet  terse  manner." — Chicago  Clinical  Review. 

"  A  timely  and  needful  book  ....  which  physicians  who  avail  themselves  of  the  use  of 
the  newer  remedies  cannot  afford  to  do  without." — The  Sanitarian. 

LABORATORY  EXERCISES  IN  BOTANY.  By  Edson  S.  Bastin, 
M.  A.,  Professor  of  Materia  Medica  and  Botany  in  the  Philadelphia  Col- 
lege of  Pharmacy.  Octavo  volume  of  540  pages,  87  full-page  plates.  Price, 
Cloth,  $2.50. 

This  work  is  intended  for  the  beginner  and  the  advanced  student,  and  it  fully 
covers  the  structure  of  flowering  plants,  roots,  ordinary  stems,  rhizomes,  tubers, 
bulbs,  leaves,  flowers,  fruits,  and  seeds.  Particular  attention  is  given  to  the  gross 
and  microscopical  structure  of  plants,  and  to  those  used  in  medicine.  Illustra- 
tions have  freely  been  used  to  elucidate  the  text,  and  a  complete  index  to  facil- 
itate reference  has  been  added. 


CATALOGUE   OF  MEDICAL    WORKS.  1 9 

SAUNDERS'  POCKET  MEDICAL  LEXICON;  or,  Dictionary  of 
Terms  and  Words  used  in  Medicine  and  Surgery.  By  John  M. 
Keating,  M.  D.,  editor  of  "Cyclopaedia  of  Diseases  of  Children,"  eic. ; 
author  of  the  "  New  Pronouncing  Dictionaiy  of  Medicine;  and  Henry 
Hamilton,  author  of  "  A  New  Translation  of  Virgil's  ^neid  into  Eng- 
lish Verse;"  co-author  of  a  "  New  Pronouncing  Dictionary  of  Medicine." 
A  new  and  revised  edition.  32nio,  282  pages.  Prices:  Cloth,  75  cents; 
Leather  Tucks,  $1.00. 

This  new  and  comprehensive  work  of  reference  is  the  outcome  of  a  demand 
for  a  more  modern  handbook  of  its  class  than  those  at  present  on  the  market, 
which,  dating  as  they  do  from  1855  to  1884,  are-of  but  trifling  use  to  the  student 
by  their  not  containing  the  hundreds  of  new  words  now  used  in  current  litera- 
ture, especially  those  relating  to  Electricity  and  Bacteriology, 

"  Remarkably  accurate  in  terminology,  accentuation,  and  ^^'nu\i\on."— Journal  of  Amer- 
ican Medical  Association. 

"Brief,  yet  complete  ....  it  contains  the  very  late.st  nomenclature  in  even  the  newest 
departments  of  medicine." — Neiv  York  Medical  Record. 


SAUNDERS'  POCKET  MEDICAL  FORMULARY.  By  William 
M.  Powell,  M.  D.,  Attending  Physician  to  the  Mercer  House  for  Invalid 
Women  at  Atlantic  City.  Containing  1750  Formulse,  selected  from  several 
hundred  of  the  be.st  known  authorities.  Forming  a  handsome  and  con- 
venient pocket  companion  of  nearly  300  printed  pages,  with  blank  leaves 
for  Additions;  with  an  Appendix  containing  Posological  Table,  Formulse 
and  Doses  for  Hypodermatic  Medication,  Poisons  and  their  Antidotes, 
Diameters  of  the  Pemale  Pelvis  and  Foetal  Head,  Obstetrical  Table,  Diet 
List  for  Various  Diseases,  Materials  and  Drugs  used  in  Antiseptic  Surgerj', 
Treatment  of  Asphyxia  from  Drowning,  Surgical  Remembrancer,  Tables 
of  Incompatibles,  Eruptive  Fevers,  Weights  and  Measures,  etc.  Third 
edition,  revised  and  greatly  enlarged.  Handsomely  bound  in  morocco, 
with  side  index,  wallet,  and  flap.     Price,  $1.75  net. 

A  concise,  clear,  and  correct  record  of  the  many  hundreds  of  famous  formulse 
which  are  found  scattered  through  the  works  of  the  most  etninent physicians 
and  surgeons  of  the  world.  The  work  is  helpful  to  the  student  and  practitioner 
alike,  as  through  it  they  become  acquainted  with  numerous  formulae  which  are 
not  found  in  text-books,  but  have  been  collected  from  among  the  rising  genera- 
tion of  the  profession,  college  professors,  and  hospital  physicians  and  siageons. 

"This  little  book,  that  can  be  conveniently  carried  in  the  pocket,  contains  an  imrnense 
amount  of  material.  It  is  very  useful,  and  as  the  name  of  the  author  of  each  prescription  is 
given  is  unusually  reliable." — New  York  Medical  Record. 

"  Designed  to  be  of  immense  help  to  the  general  practitioner  in  the  exercise  of  his  daily 
calling." — Boston  Medical  and  Surgical  yournal. 


20  W.   B.    SAUNDERS' 


HOW    TO    EXAMINE    FOR    LIFE   INSURANCE.     By  John    M. 

Keating,  M.  D.,  Fellow  of  the  College  of  Physicians  and  Surgeons  of 
Philadelphia;  Vice-President  of  the  American  Pajdiatric  Society;  Ex- 
President  of  the  i\ssociation  of  Life  Insurance  Medical  Directors.  Royal 
8vo,  211  pages,  with  two  large  phototype  illustrations,  and  a  plate  pre-_ 
pared  by  Dr.  McClellan  from  special  dissections ;  also,  numerous  cuts  to 
elucidate  the  text.     Second  edition.     Price,  in  Cloth,  $2.00  net. 

Part  I.,  which  has  been  carefully  prepared  from  the  best  works  on  Physical 
Diagnosis,  is  a  short  and  succinct  account  of  the  methods  used  to  make 
examinations  ;  a  description  of  thp  normal  condition  and  of  the  earliest 
evidences  of  disease. 

Part  II.  contains  the  Instructions  of  twenty-four  Life  Insurance  Companies  to 
their  medical  examiners. 

"  This  is  by  far  the  most  useful  book  which  has  yet  appeared  on  insurance  examination,  a 
subject  of  growing  interest  and  importance.  Not  the  least  valuable  portion  of  the  volume  is 
Part  II.,  which  consists  of  instructions  issued  to  their  examining  physicians  by  twent)'-four 
representative  companies  of  this  country.  As  the  proofs  of  these  instructions  were  corrected 
by  the  directors  of  the  companies,  they  form  the  latest  instructions  obtainable.  If  for  these 
alone,  the  book  should  be  at  the  right  hand  of  every  physician  interested  in  this  special  branch 
of  medical  science." — The  Medical  News,  Philadelphia. 


MANUAL  OF  MATERIA  MEDICA  AND  THERAPEUTICS. 

By  A.  A.  Stevens,  A.  M.,  M.  D.,  Instructor  of  Physical  Diagnosis  in  the 
University  of  Pennsylvania,  and  Demonstrator  of  Pathology  in  the  Woman's 
Medical  College  of  Philadelphia.     435  pages.     Price,  Cloth,  ^2.25. 

This  wholly  new  volume,  which  is  based  on  the  1890  edition  of  the  Pharma- 
copoeia, comprehends  the  following  sections  :  Physiological  Aciion  of  Drugs ; 
Drugs;  Remedial  Measures  other  than  Drugs;  Applied  Therapeutics;  Incom- 
patibility in  Prescriptions;  Table  of  Doses;  Index  of  Drugs;  and  Index  of 
Diseases;  the  treatment  being  elucidated  by  more  than  two  hundred  formulge. 

"The  author  is  to  be  congratulated  upon  having  presented  the  medical  student  with  as 
accurate  a  manual  of  therapeutics  as  it  is  possible  to  prepare."— 7%^r«/^«2'/<:  (gazette. 

"  Far  superior  to  most  of  its  class  ;  in  fact,  it  is  very  good.  Moreover,  the  book  is  reliable 
and  accurate." — New  York  Medical  Jour  77  al . 

"The  author  has  faithfully  presented  modern  therapeutics  in  a  comprehensive  work.  .  .  . 
and  it  will  be  found  a  reliable  g\i\d&."—U7ti7>ersity  Medical  Magai.inr. 

"Will  be  of  immense  service  to  the  busy  ^^x'3.c\:\\:\ow&x."  —Medical  Reporter  (Calcutta). 

"  Reliable  and  ^\mt^y ." — North  American  Practitioner. 

"Concise,  up  to  date,  and  withal  comprehensive."— /'«cz/?^  Medical  Journal. 


SAUNDERS'  QUESTION  COMPENDS. 

Arranged  in  Question  and  Answer  Form. 

THE  LATEST,  CHEAPEST,  and  BEST  ILLUSTEATED 
SEEIES  OF  COMPENLS  EVER  ISSUED. 


Now  the  Standard  Authorities  in  Medical  Literature 


students  and  Practitioners  in  every  City  of  the  United 
States  and  Canada. 


THE    REASON    \VHY. 

They  are  the  advance  guard  of  "  Student's  Helps  " — that  DO  help;  they  are 
the  leaders  in  their  special  line,  well  and  authoritatively  written  by  able  men, 
who,  as  teachers  in  the  large  colleges,  know  exactly  ivhat  is  wanted  by  a  student 
preparing  for  his  exafninations.  The  judgment  exercised  in  the  selection  of 
authors  is  fully  demonstrated  by  their  professional  elevation.  Chosen  from  the 
ranks  of  ^Demonstrators,  Quiz-masters,  and  Assistants,  most  of  them  have  be- 
come Professors  and  Lecturers  in  their  respective  colleges. 

Each  book  is  of  convenient  size  (5x7  inches),  containing  on  an  average  250 
pages,  profusely  illustrated,  and  elegantly  printed  in  clear,  readable  t}'pe,  on 
fine  paper. 

The  entire  series,  numbering  twenty- four  subjects,  has  been  kept  thoroughly 
revised  and  enlarged  when  necessaiy,  many  of  them  being  in  their  fourth  and 
fifth  editions. 

TO    SUM    UP. 

Although  there  are  numerous  other  Quizzes,  Manuals,  Aids,  etc.  in  the  mar- 
ket, none  of  them  approach  the  "  Blue  Series  of  Question  Compends;"  and 
the  claim  is  made  for  the  following  points  of  excellence  : 

1.  Professional  distinction  and  reputation  of  authors. 

2.  Conciseness,  clearness,  and  soundness  of  treatment. 

3.  Size  of  type  and  quality  of  paper  and  binding. 

■*;:r  Any  of  these  Compends  will  be  mailed  on  recei-)'-  of  price. 

21 


22  W.   B.    SAUNDERS' 


I.  ESSENTIALS  OF  PHYSIOLOGY.  By  H.  A.  Hare,  M.  D.,  Pro- 
fessor of  Therapeutics  and  Materia  Medica  in  the  Jefferson  Medical  Col- 
lege of  Philadelphia;  Physician  to  St.  Agnes'  Hospital  and  to  the  Medical 
Dispensary  of  the  Children's  Hospital;  Laureate  of  the  Royal  Academy 
of  Medicine  in  Belgium,  of  the  Medical  Society  of  London,  etc.  Third 
edition,  revised  and  enlarged  by  the  addition  of  a  series  of  handsome 
plate  illustrations  taken  from  the  celebrated  "  Icones  Nervorum  Capitis'' 
of  Arnold.  Crown  8vo,  230  pages,  numerous  illustrations.  Price,  Cloth, 
^i.oo  net;  interleaved  for  notes,  $1.25  net. 

"An  exceedingly  useful  little  compend.  The  author  has  done  his  work  thoroughly  and 
well.  The  plates  of  the  cranial  nerves  from  Arnold  are  superb." — Jourtial  of  American 
Medical  Association. 


2.  ESSENTIALS    OF    SURGERY,  containing  also  Venereal    Diseases, 

Surgical  Landmarks,  Minor  and  Operative  Surgery,  and  a  Complete  De- 
scription, together  with  full  Illustrations,  of  the  Handkerclyef  and  Roller 
Bandages.  By  Edward  Martin,  A.M.,  M.D.,  Clinical  Professor  of 
Genito-Urinary  Diseases,  Instructor  in  Operative  Surgery,  and  Lecturer  on 
Minor  Surgery,  University  of  Pennsylvania;  Surgeon  to  the  Howard  Hos- 
pital; Assistant  Surgeon  to  the  University  Hospital,  etc.  Fifth  edition. 
Crown  8vo,  334  pages,  profusely  illustrated.  Considerably  enlarged  by 
an  Appendix  containing  full  directions  and  prescriptions  for  the  prepara- 
tion of  the  various  materials  used  in  Antiseptic  Surgery ;  also  several 
hundred  recipes  covering  the  medical  treatment  of  surgical  affections. 
Price,  Cloth,  ^i.oo;  interleaved  for  notes,  $1.25. 

"Written  to  assist  the  student,  it  will  be  of  undoubted  value  to  the  practitioner,  contain- 
ing as  it  does  the  essence  of  surgical  work." — Boston  Medical  and  Surgical  Journal. 

"  Cleverly  combines  all  the  merits  of  condensation,  while  avoiding  the  errors  of  super- 
ficiality and  inaccuracy." — University  Medical  Magazine. 

3.  ESSENTIALS    OF    ANATOMY,  including  the  Anatomy  of  the 

Viscera.  By  Charles  B.  Nancrede,  M.  D.,  Professor  of  Surgery  and 
of  Clinical  Surgery  in -the  University  of  Michigan,  Ann  Arbor;  Cor- 
responding Member  of  the  Royal  Academy  of  Medicine,  Rome,  Italy; 
late  Surgeon  to  the  Jefferson  Medical  College,  etc.  Fifth  edition.  Crown 
8vo,  380  pages,  180  illustrations.  Enlarged  l)y  an  Appendix  containing 
over  sixty  illustrations  of  the  O.steology  of  the  Human  Body.  The  whole 
based  upon  the  last  (eleventh)  edition  of  Gray's  Anatomy.  Price,  Cloth, 
^i.oo;  interleaved  for  notes,  $1.25. 

"Truly  such  a  book  as  no  student  can  afford  to  be  \N\tho\\i."— American  Practitioner 
and  News. 

"The  questions  have  been  wisely  selected    and  the  answers  accurately  and  concisely 
given." — University  Medical  Magazine. 


\ 


CATALOGUE    OF  MEDICAL    WORKS.  23 

4.  ESSENTIALS   OF  MEDICAL  CHEMISTRY,  ORGANIC  AND 

INORGANIC,  containing  also  Questions  on  Medical  Physics,  Chen:iical 
Physiology,  Analytical  Processes,  Urinalysis,  and  Toxicology.  By  Law- 
rence Wolff,  M  D.,  Demonstrator  of  Chemistry,  Jefferson  Medical  Col- 
lege; Visiting  Physician  to  the  German  Hospital  of  Philadelphia;  Member 
of  Philadelphia  College  of  Pharmacy,  etc.  Fourth  and  revised  edition, 
with  an  Appendix.  Crown  8vo,  212  pages.  Price,  Cloth,  ^i.oo;  inter- 
leaved for  notes,  $1.25. 

"  The  scope  of  this  work  is  certainly  equal  to  that  of  the  best  course  of  lectures  on  Med- 
ical Chemistry." — Pharmaceutical  Era. 

"  We  could  wish  that  more  books  like  this  would  be  written,  in  order  that  medical  students 
might  thus  early  become  interested  in  what  is  often  a  difficult  and  uninteresting  branch  of 
medical  study." — Medical  and  Surgical  Reporter. 

5.  ESSENTIALS    OF    OBSTETRICS.     By  W.   Easterly   Ashton, 

M.  D.,  Professor  of  Gynecology  in  the  Medico-Chirurgical  College  of 
Philadelphia;  Obstetrician  to  the  Philadelphia  Hospital.  Third  edition, 
thoroughly  revised  and  enlarged.  Crown  8vo,  244  pages,  75  illustrations. 
Price,  Cloth,  $1.00  ;  interleaved  for  notes,  ^1.25. 

"  An  excellent  little  volume  containing  correct  and  practical  knowledge.  An  admirable 
compend,  and  the  best  condensation  we  have  seen." — Souther-n  Practitioner. 

"Of  extreme  value  to  students,  and  an  excellent  little  book  to  freshen  up  the  memory  of 
the  practitioner." — Chicago  Medical  Times. 

6.  ESSENTIALS     OF     PATHOLOGY    AND    MORBID    ANAT- 

OMY. By  C.  E.  Armand  Semple,  B.  A.,  M.  B.,  Cantab.  L.  S.  A., 
M.  R.  C.  P.  Lond.,  Physician  to  the  Northeastern  Hospital  for  Children, 
Hackney;  Professor  of  Vocal  and  Aural  Physiology  and  Examiner  in 
Acoustics  at  Trinity  College,  London,  etc.  Crown  8vo,  174  pages,  illus- 
trated.    Sixth  thousand.    Price,  Cloth,  ^r.oo;  interleaved  for  notes,  $1.25. 

"A  valuable  little  volume — truly  a  mtdtuni  inparvo." — Cincinnati  Medical  News. 

"The  volume  is  very  comprehensive,  covering  the  entire  field  of  pathologj'." — St.  Joseph 
Medical  Herald. 

7.  ESSENTIALS    OF   MATERIA    MEDICA,    THERAPEUTICS, 

AND  PRESCRIPTION-WRITING.  By  Henry  Morris,  M.  D., 
late  Demonstrator,  Jefferson  Medical  College ;  Fellow  of  the  College  of 
Physicians,  Philadelphia;  co-editor  Biddle's  Materia  Medica;  Visiting 
Physician  to  St.  Joseph's  Hospital,  etc.  Fourth  edition.  Crown  Svo,  250 
pages.     Price,  Cloth,  $1.00;  interleaved  for  notes,  $1.25. 

"One  of  the  best  compends  in  this  series.  Concise,  pithy,  and  clear,  well  suited  to  the 
purpose  for  which  it  is  prepared." — Medical  and  Surgical  Reporter. 

"The  subjects  are  treated  in  such  a  unique  and  attractive  manner  that  they  cannot  fail  to 
impress  the  mind  and  instruct  in  a  lasting  manner." — Buffalo  Medical  and  Surgical  yournal. 


24  ^f^-   B.    SAUNDERS' 


8,  9.  ESSENTIALS  OF  PRACTICE  OF  MEDICINE.  By  Henry 
Morris,  M.  D.,  author  of  "  Essentials  of  Materia  Medica,"  etc.,  with  an 
Appendix  on  the  Clinical  and  Microscopical  Examination  of  Urine,  by 
Lawrence  Wolff,  M.  D.,  author  of  "  Essentials  of  Medical  Chemistry," 
etc.  Colored  (Vogel)  urine  scale  and  numerous  fine  illustrations.  Third 
edition,  enlarged  by  some  three  hundred  essential  formulae,  selected  from 
the  writings  of  the  most  eminent  authorities  of  the  medical  profession, 
collected  and  arranged  by  WiLLiAM  M.  Powell,  M.  D.,  author  of 
"Essentials  of  Diseases  of  Children."  Crown  8vo,  460  pages.  Price, 
Cloth,  $2.00. 

"  The  teaching  is  sound,  the  presentation  graphic,  matter  as  full  as  might  be  desired,  and 
the  style  attractive." — Atnerican  Practitioner  and  Neivs. 

"A  first-class  practice  of  medicine  boiled  down,  and  giving  the  real  essentials  in  as  few 
words  as  is  consistent  with  a  thorough  understanding  of  the  subject." — Medical  Brief. 

"  Especially  full,  and  an  excellent  illustration  of  what  the  best  of  the  compends  can  be 
made  to  be." — Gailiard's  Medical  Journal. 


10.  ESSENTIALS  OF  GYNECOLOGY.  By  Edwin  B.  Cragin, 
M.  D.,  Attending  Gynaecologist,  Roosevelt  Hospital,  Out-Patients'  Depart- 
ment; Assistant  Surgeon,  New  York  Cancer  Hospital,  etc.  Fourth  edi- 
tion, revised.  Crown  8vo,  198  pages,  62  fine  illustrations.  Price,  Cloth, 
^l.oo;  interleaved  for  notes,  $1.25. 

"  This  is  a  most  excellent  addition  to  this  series  of  question  compends.  The  style  is  con- 
cise, and  at  the  same  time  the  sentences  are  well  rounded.  This  renders  the  book  far  more 
ea-sy  to  read  than  most  compends,  and  adds  distinctly  to  its  value." — Medical  and  Surgical 
Reporter. 

"  Useful  not  only  to  the  student  who  is  barely  at  the  threshold  of  professional  life,  but  to 
the  busy  practitioner  as  well." — New  York  Medical  yournal. 


II.  ESSENTIALS  OF  DISEASES  OF  THE  SKIN.  By  Henry  W. 
Stelwagon,  M.  D.,  Clinical  Lecturer  on  Dermatology  in  the  Jefferson 
Medical  College,  Philadelphia;  Physician  to  the  Skin  Service  of  the 
Northern  Dispensary;  Dermatologist  to  Philadelphia  Hospital;  Physician 
to  Skin  Department  of  the  Howard  Hospital ;  Clinical  Professor  of  Der- 
matology in  the  Woman's  Medical  College,  Philadelphia,  etc.  Third  edi- 
tion. Crown  8vo,  270  pages,  86  illustrations,  many  of  which  are  original. 
Price,  Cloth,  $l  oo;  interleaved  for  notes,  ^1.25  net. 

"  An  immense  amount  of  literature  has  been  gone  over  and  judiciously  condensed  by  the 
writer's  skill  and  experience." — New  York  Medical  Record. 

"  The  book  admirably  answers  the  purpose  for  which  it  is  written.     The  experience  of  the 
reviewer  has  taught  him  that  just  such  a  book  is  needed." — Ne7v  York  Medical  Journal, 


CATALOGUE   OF  MEDICAL    WORKS.  -  2$ 


12.  ESSENTIALS  OF  MINOR  SURGERY,  BANDAGING,  AND 
VENEREAL  DISEASES.  By  Edward  Martin,  A.M.,  M.  D., 
author  of  "  Essentials  of  Surgery,"  elc.  Second  edition.  Crown  8vo, 
thoroughly  revised  and  enlarged,  78  illustrations.  Price,  Cloth,  $1.00; 
interleaved  for  notes,  ^1.25. 

"Characterized  by  the  same  literary  excellence  that  has  distinguished  previous  numbers 
of  this  series  of  compends." — American  Practitioner  and  News. 

"The  best  condensation  of  the  subjects   of  which  it  treats    yet  placed  before  the  pro- 
fession."—^i-^/crt/  News,  Philadelphia. 

"  A  capital  little  book.     The  illustrations  are  remarkably  clear  and  intelligible." — Aus- 
tralian Medical  Gazette. 

"We  have  nothing  but  praise  for  the  subject-matter  of  this  hod\^."— Bristol  Medico-Chi- 
ru  r^ical  Journal. 


13.  ESSENTIALS  OF  LEGAL  MEDICINE,  TOXICOLOGY, 
AND  HYGIENE.  By  C.  E.  Armand  Semple,  M.  D.,  author  of  "  Es- 
sentials of  Pathology  and  Morbid  Anatomy."  Crown  8vo,  212  pages, 
130  illustrations.     Price,  Cloth,  ^i.oo;  interleaved  for  notes,  $1.25. 

"  The  leading  points,  the  essentials  of  this  too  much  neglected  portion  of  medical  science, 
are  here  summed  up  systematically  and  clearly." — Southern  Practitioner. 

"  But  for  the  author's  judicious  condensation  of  facts,  the  information  it  contains  would  be 
sufficient  to  fill  an  ordinary  octavo  volume." — College  and  Clinical  Record. 


14.  ESSENTIALS  OF  REFRACTION  AND  DISEASES  OF 
THE  EYE.  By  Edward  Jackson,  A.M.,  M.  D.,  Professor  of  Dis- 
eases of  the  Eye  in  the  Philadelphia  Polyclinic  and  College  for  Graduates 
in  Medicine;  Member  of  the  American  Ophthalmological  Society;  Fel- 
low of  the  College  of  Physicians  of  Philadelphia  ;  Fellow  of  the  American 
Academy  of  Medicine,  etc. ;  and  ESSENTIALS  OF  DISEASES  OF 
THE  NOSE  AND  THROAT.  By  E.  Baldwin  Gleason,  S.  B., 
M.  D.,  Clinical  Professor  of  Otology,  Medico-Chirurgical  College,  Phila- 
delphia; Surgeon  in  charge  of  the  Nose,  Throat,  and  Ear  Department  of 
the  Northern  Dispensary  of  Philadelphia ;  formerly  Assistant  in  the  Nose 
and  Throat  Dispensary  of  the  Hospital  of  the  University  of  Pennsylvania, 
and  Assistant  in  the  Nose  and  Throat  Department  of  the  Union  Dispen- 
saiy,  etc.  Two  volumes  in  one.  Second  edition.  Crown  8vo,  294  pages, 
124  illustrations.     Price,  Cloth,  $1.00;  interleaved  for  notes,  $1.25. 

"A  valuable  book  to  the  beginner  in  these  branches,  to  the  student,  to  the  busy  prac- 
titioner, and  as  an  adjunct  to  more  thorough  reading.  1  he  authors  are  capable  men,  and  as 
successful  teachers,  know  what  a  student  most  needs." — New  York  Medical  Record. 

"  Verj'  valuable,  since  in  both  sections  is  given  about  all  that  a  candidate  for  examination 
is  required  to  knowf ." —Medical  Times  and  Hospital  Gazette. 


26  JV.   B.    SAUNDERS' 


15.  ESSENTIALS  OF  DISEASES  OF  CHILDREN.  By  William 
M.  Powell,  M.D.,  Attending  Physician  to  the  Mercer  House  for  InvaUd 
Women  at  Atlantic  Ciiy,  N.J. ;  late  Physician  to  the  Clinic  for  the  Dis- 
eases of  Children  in  the  Hospital  of  the  University  of  Pennsylvania  and 
St.  Clement's  Hospital ;  Instructor  in  Physical  Diagnosis  in  the  Medical 
Department  of  the  University  of  Pennsylvania.  Crown  8vo,  216  pages. 
Price,  Cloth,  $1.00;  interleaved  for  notes,  $1.25. 

"  This  work  is  gotten  up  in  the  clear  and  attractive  style  that  characterizes  the  Saunders 
Series.  It  contains  in  appropriate  form  the  gist  of  all  the  best  works  in  the  department  to 
which  it  relates." — American  Practitioner  and  News. 

"  The  book  contains  a  series  of  important  questions  and  answers,  which  the  student  will 
find  of  great  utility  in  the  examination  of  children." — Annals  of  Gynecology. 

16.  ESSENTIALS  OF  EXAMINATION  OF  URINE.  By  Law- 
rence Wolff,  M.  D.,  author  of  "  Essentials  of  Medical  Chemistry/'  etc. 
Colored  (Vogel)  urine  scale  and  numerous  illustrations.  Crown  8vo. 
Price,  Cloth,  75  cents. 

"  A  little  work  of  decided  value." — University  Medical  Magazine. 

"  A  good  manual  for  students,  well  written,  and  answers,  categorically,  many  questions 
beginners  are  sure  to  ask." — Ne7v  York  Medical  Record. 

"  The  questions  have  been  well  chosen,  and  the  answers  are  clear  and  brief.  The  book 
cannot  fail  to  be  useful  to  students." — Medical  atid  Surgical  Reporter . 

17.  ESSENTIALS    OF    DIAGNOSIS.      By   Solomon   Solis-Cohen, 

M.  D.,  Professor  of  Clinical  Medicine  and  Applied  Therapeutics  in  the 

Philadelphia  Polyclinic,  and  Augu.stus  A.  Eshner,  M.  D.,  Instructor  in 

Clinical  Medicine,  Jefferson  Medical  College,  Philadelphia.     Crown  8vo, 

382  pages,  55  illustrations,  some  of  which  are  colored,  and  a  frontispiece. 

Price,  $1.50  net. 

"A  good  book  for  the  student,  properly  written  from  their  standpoint,  and  confines  itself 
well  to  its  X^-K\."^Neiv  York  Medical  Record. 

"Concise  in  the  treatment  of  the  subject,  terse  in  expression  of  fact.  .  .  .  The  work  is 
reliable,  and  represents  the  accepted  views  of  clinicians  of  to-day." — American  Journal  of 
Medical  Sciences. 

"The  subjects  are  explained  in  a  few  well-selected  words,  and  the  required  ground  has 
been  thoroughly  gone  over." — Internatio7ial  Medical  Magazine. 

18.  ESSENTIALS  OF  PRACTICE  OF  PHARMACY.     By  Lucius 

E.  Sayre,  M.  D.,  Professor  of  Pharmacy  and  Materia  Medica  in  the  Uni- 
versity of  Kansas.  Second  edition,  revised  and  enlarged.  Crown  8vo, 
200  pages.     Price,  Cloth,  ^i.oo;  interleaved  for  notes,  ^1.25. 

"Covers  a  great  deal  of  ground  in  small  compass.  The  matter  is  well  digested  and 
arranged.  The  research  questions  are  a  valuable  feature  of  the  book." — Albany  Medical 
Annals. 

"  The  best  quiz  on  Pharmacy  we  have  yet  examined." — National  Drug  Register. 

"  The  veteran  pharmacist  can  peruse  it  with  pleasure,  because  it  emphasizes  his  grasp 
upon  knowledge  already  gleaned." — Western  Drug  Record. 


CATALOGUE    OF  MEDICAL    WORKS.  2/ 


20.  ESSENTIALS  OF  BACTERIOLOGY:  A  Concise  and  Syste- 
matic Introduction  to  the  Study  of  Micro-organisms.  By  M.  V, 
Ball,  M.  D.,  Assistant  in  Microscopy,  Niagara  University,  Buffalo,  N.  Y. ; 
late  Resident  Physician,  German  Hospital,  Philadelphia,  etc.  Second  edi- 
tion, revised.  Crown  8vo,  200  pages,  81  illustrations,  some  in  colors,  and 
5  plates.     Price,  Cloth,  ^ 1. 00;  interleaved  for  notes,  ^1.25. 

"The  amount  of  material  condensed  in  this  little  book  is  so  great,  and  so  accurate  are 
the  formulse  and  methods,  that  it  will  be  found  useful  as  a  laboratory  Y^^x^AhooV."— Medical 
Netvs. 

"  Bacteriology  is  the  keynote  of  future  medicine,  and  every  physician  who  expects  success 
must  familiarize  himself  with  a  knowledge  of  germ-life— the  agents  of  disease.  This  little 
book,  with  its  beautiful  illustrations,  will  give  the  students,  in  brief,  the  results  of  years  of 
study  and  research  unaided. 'I— Prtcz/fc  Record  of  Medicine  and  Surgery. 

"Thoroughly  practical,  very  concise,  clear,  well-written,  and  sufficiently  illustrated.  .  .  . 
The  best  book  of  the  kind  in  the  English  language." — Medical  and  Surgical  Reporter. 

21.  ESSENTIALS  OF  NERVOUS  DISEASES  AND  INSANITY, 
their  Symptoms  and  Treatment.  By  John  C.  Shaw,  M.  D.,  Clinical 
Professor  of  Diseases  of  the  Mind  and  Nervous  System,  Long  Island  Col- 
lege Hospital  Medical  School;  Consulting  Neurologist  to  St.  Catherine's 
Hospital  and  to  the  Long  Island  College  Hospital ;  formerly  Medical  Super- 
intendent King's  County  Insane  Asylum.  Second  edition.  Crown  Svo,  186 
pages,  48  original  illustrations,  mostly  selected  from  the  Author's  private 
practice.     Price,  Cloth,  |5i.oo;  interleaved  for  notes,  ^1.25. 

"Clearly  and  intelligently  written." — Boston  Medical  and  Surgical  Journal. 

"  A  valuable  addition  to  this  series  of  compends,  and  one  that  cannot  fail  to  be  appreciated 
by  all  physicians  and  students." — Medical  Brief. 

"  Dr.  Shaw's  Primer  is  excellent.  The  engravings  are  well  executed  and  very  interest- 
ing.''— Medical  Ti?nes  and  Register. 

"  Written  with  great  clearness,  devoid  of  verbosity,  it  encompasses  in  a  brief  space  a  vast 
amount  of  valuable  information." — Pacific  Medical  Record. 

22.  ESSENTIALS   OF    PHYSICS.      By  Fred  J.    Brockway,   M.  D., 

Assistant  Demonstrator  of  Anatomy  in  the  College  of  Physicians  and  Sur- 
geons, New  York.  Second  edition.  Crown  Svo,  320  pages,  155  fine  illus- 
trations.    Price,  Cloth,  ^i.oo  net ;   interleaved  for  notes,  ^1.25  net. 

The  publisher  has  again  shown  himself  as  fortunate  in  his  editor  as  he  ever  has  been  in 
the  attractive  style  and  make-up  of  his  com-^^-n^s."  —American  Practitioner  and  News. 

"Contains  all  that  one  need  know  of  the  subject,  is  well  written,  and  is  copiously  \\\\i%- 
trated."— iV^'iJw  York  Medical  Record. 

"The  author  has  dealt  with  the  subject  in  a  manner  that  will  make  the  theme  not  only 
comparati%'ely  easy,  but  also  of  \n\.&rts\.."— Medical  News,  Philadelphia. 

"  Deserving  of  close  investigation  at  the  hands  of  students  and  physicians."— ^w^rzVaw 
Gynecological  Journal . 


28  jr.    B.   SAUNDERS'    CATALOGUE. 

23.    ESSENTIALS     OF    MEDICAL    ELECTRICITY.     By   D.    D. 

Stewart,  M.  D.,  Demonstrator  of  Diseases  of  the  Nervous  System  and 
Chief  of  the  Neurological  Clinic  in  the  Jefferson  Medical  College ;  Phy- 
sician to  St.  Mary's  Hospital  and  to  St.  Christopher's  Hospital  for  Chil- 
dren, etc. ;  and  E.  S.  Lawrance,  M.  D.,  Chief  of  the  Electrical  Clinic, 
and  Assistant  Demonstrator  of  Diseases  of  the  Nervous  System  in  the 
Jefferson  Medical  College,  etc.  Crown  8vo,  148  pages,  65  illustrations. 
Price,  Cloth,  $1.00;  interleaved  for  notes,  $1.25. 

"  Clearly  written,  and  affords  a  safe  guide  to  the  beginner  in  this  subject." — Boston  Med- 
ical and  Surgical  Journal. 

"  The  subject  is  presented  in  a  lucid  and  pleasing  manner." — Neiv  York  Medical  Record. 

"  A  litde  work  on  an  important  subject,  which  will  prove  of  great  value  to  medical  students 
and  trained  nurses  who  wish  to  study  the  scientific  as  well  as  the  practical  points  of  elec- 
tricity."—  T/ie  Hospital,  London. 

"  The  selection  and  arrangement  of  material  are  done  in  a  skilful  manner.  It  gives,  in  a 
condensed  form,  the  principles  and  science  of  electricity  and  their  application  in  the  practice 
of  medicine." — Annals  of  Surgery. 

"  The  compilation  is  a  good  one,  and  will  be  found  useful  both  to  students  and  to  men  in 
practice." — New  Zealand  Medical  Journal. 


24.    ESSENTIALS    OF    DISEASES    OF    THE    EAR.     By  E.  B. 

Gleason,  S.  B.,  M.  D.,  Clinical  Professor  of  Otology,  Medico-Chirurgical 
College,  Philadelphia;  Surgeon  in  Charge  of  the  Nose,  Throat,  and  Ear 
Department  of  the  Northern  Dispensary  of  Philadelphia;  formerly  As- 
sistant in  the  Nose  and  Throat  Dispensary  of  the  Hospital  of  the  Univer- 
sity of  Pennsylvania,  and  Assistant  in  the  Nose  and  Throat  Department 
of  the  Union  Dispensary.  89  illustrations.  Price,  Cloth,  ^i. 00;  inter- 
leaved for  notes,  ^1.25. 

This  latest  addition  to  the  Saunders  Compend  Series  accurately  represents 
the  modern  aspect  of  otological  science.  The  effort  has  been  made  to  state  the 
Essentials  of  Otology  concisely,  without  sacrificing  accuracy  to  brevity,  and  the 
book,  while  small  in  compass,  is  logically  and  capably  written;  it  comprises  up- 
ward of  150  pages,  with  89  illustrations,  most  of  which  are  from  original 
sources. 


DIET  LISTS  AND  SICK-ROOM  DIETARY.    By  Jerome  B.  Thomas^ 
M.  D. 

There  is  here  offered,  in  portable  form,  as  an  efficient  aid  to  the  better  prac- 
tice of  Therapeutics,  a  collection  of  Diet  Lists  and  a  Sick-room  Dietary.  It  meets 
a  want,  for  the  busy  practitioner  has  but  little  time  to  write  out  Systems  of  Diet 
approjjriate  to  his  patients,  or  to  describe  the  preparati(;n  of  their  food.  Com- 
piled from  the  mo.st  modern  works  on  dietetics,  the  Dietary  offers  a  variety  of 
easily-digested  foods.     Send  for  .sample  sheet.     Price,  ^i.oo. 


COLUMBIA   UNIVERSITY   LIBRARIES 

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[ 

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COLUMBIA  UNIVERSITY  LIBRARIES  IteLstx) 

RD91B381895C 

A  manual  ot  tnri_moo>r,_^^^_;^  -  j,|<,||,|„|,|,||„| 


2002110245 


RD91 


Beck 


B38 
1895 


A  manu&l   of  the  modern  theory  and 
-technique  of   siirgicai  a  sepsis.  j== 

m  PERSONAL  RfifiNERVE  SHELF 


RD31 


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